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DISEASE 


OF   THE 


Fallopian   Tubes 


AND 


HISTORIES  OF    FOURTEEN  CASES    OPERATED 
UPON  AND  REPORTS  ON  SPECIMENS 


By   W.  gill  WYLIE,   M.D. 

PROFESSOR    GYNECOLOGY    IN   THE    NEW    YORK     POLYCLINIC     AND     GYNECOLOGIST 
TO    BELLEVUE   HOSPITAL,    N.    Y.,    ETC. 


Reprinted  fro7n  THE  MEDICAL  RECORD,  Janvai-y  24  and 
February  7,  1885 


NEW   YORK 
TROWS  PRINTING  AND  BOOKBINDING  COMPANY 

201-213  East  Twelfth  Street 
1885 


DISEASES  OF  THE  FALLOPIAxN  TUI5ES.' 


In  looking  up  the  literature  of  salpingitis,  minute  de- 
scriptions of  the  pathological  anatomy  will  be  found  in 
the  writings  of  Kiwisch,  Forster,  Rokitansky,  and  later 
Martin  Klob,  Schroder,  Henning,  and  other  German 
writers  ;  but  little  advance  was  made  in  the  treatment 
until  a  few  years  ago,  when  Mr.  Lawson  Tait  made 
known  his  wonderful  success  in  removing  diseased  tubes. 
The  writings  of  Battey  and  Hegar  on  removal  of  ovaries 
also  had  an  influence  in  developing  the  proper  plan  of 
treating  diseases  of  the  uterine  appendages." 

Dr.  J.  Marion  Sims,  for  several  years  before  his  death, 
was  much  interested  in  the  subject,  and,  as  his  assistant, 
I  helped  him  in  a  number  of  cases.  But  it  was  not  until  I 
was  appointed  one  of  the  gynecologists  to  Bellevue  Hos- 
pital and  began  my  clinics  at  the  New  York  PolycUnic, 
in  1882,  that  I  had  an  opportunity  to  study  cHnically  a 
large  number  of  cases.  Since  then  I  have  made  a  careful 
study  of  the  subject,  and  since  May,  1883,  when  I  did  my  ^ 
first  operation  for  removal  of  diseased  tubes,  I  have  oper- 
ated upon  fourteen  cases  for  diseased  uterine  appendages, 
not  including  operations  for  ovarian  or  uterine  tumors. 
Each  of  the  fourteen  cases  were  under  my  observation  and 
treatment  several  weeks  before  the  operation,  and  many 
had  been  kept  in  my  ward  at  Bellevue  three,  six,  and  one 

1  Read  before  the  New  York  Academy  of  Medicine,  January  15,  1885. 
j3  2  The  author  does  not  desire  to  discuss  the  claims  of  Tait,  Battey,  and  Hegar, 
►--put  there  can  be  litde  question  that,  among  the  English  speaking  profession,  Eattey 
first  made  plain  that  we  should  operate  upon  certain  forms  of  ovarian  trouble  besides 
ovarian  tumors,  and  Lawson  Tait  first  taught  us  that  we  should  and  could  remove 
diseased  Fallopian  tubes  in  many  cases.  Hegar  may  have  done  the  same  thing 
in  Germany. 


or  two  even  nine  months  beforehand.  By  a  careful  study 
of  each  case  and  by  the  use  of  preparatory  treatment  to 
soften  and  relax  the  adhesions,  I  was  able,  in  almost 
every  case,  to  make  a  more  or  less  exact  diagnosis  be- 
fore operating.  Of  these,  nine  were  operated  upon  in 
either  the  Sturges  or  the  Marquand  paviUon  at  Bellevue 
Hospital,  the  remaining  five  were  in  private  practice. 
Twelve  recovered  and  two  died  of  septicaemia  on  the 
fifth  day ;  the  latter  were  hospital  cases.  Eight  were 
cases  of  pyo-salpinx  ;  two  hydro-salpinx,  and  four  ca- 
tarrhal tubes  with  peritoneal  adhesions.  With  one  or 
two  exceptions,  there  were  extensive  adhesions  from  local 
peritonitis  and  the  ovaries  were  either  diseased  or  more 
or  less  covered  with  adhesions,  and,  in  three  instances, 
abscesses  were  found  involving  the  extremities  of  the 
tubes  and  the  ovaries.  Short  histories  of  each  case  were 
read,  and  twelve  of  the  fourteen  specimens,  with  a  re- 
port on  the  specimens  by  Dr.  H.  C.  Coe,  Pathologist 
ogist  to  the  Woman's  Hospital  of  the  State  of  New  York, 
were  shown  last  night  at  the  New  York  Pathological 
Society.  Many  other  cases  were  kept  under  observation 
and  clearly  diagnosed,  but  either  because  the  patients  ob- 
jected to  the  operation,  or  the  subjective  symptoms  did 
not  justify  it,  they  were  not  operated  upon. 

I  am  satisfied  that  a  careful  study  of  the  diseases  of 
.the  Fallopian  tubes  will  not  only  clear  up  most  of  those 
numerous  and  once  incurable  cases  of  local  peritonitis 
(in  this  country  commonly  called  celluHtis),  but  also 
most  of  the  cases  of  retroversion,  retroflexion,  and  lateral 
flexions  with  adhesions,  and  that  their  proper  treatment 
will  make  plain  the  uselessness  and  danger  of  using  pes- 
saries in  such  cases.  I  do  not  mean  to  say  that  every 
case  of  local  peritonitis  will  be  found  due  to  salpingitis, 
but  that,  in  the  large  majority  of  cases,  salpingitis  pre- 
cedes the  local  peritonitis,  and  that  repeated  attacks  of 
local  peritonitis  are,  as  a  rule,  caused  by  salpingitis. 

In  my  opinion  v/hen  the  frequency  and  the  great  im- 
portance of  diseases  of  the  Fallopian  tubes  is  generally 


understood,  the  fascinating  teaching  of  the  mechanical 
pathologist,  namely,  that  most  of  the  ills  of  women  are 
due  to  uterine  displacements,  that  the  real  disease  is  the 
version  or  flexion,  and  when  this  is  corrected  and  the 
uterus  is  held  by  a  pessary  in  an  ideal  normal  ijosition 
that  all  will  be  well,  will  fade  to  small  proportions  and 
the  relatively  few  Hues  now  to  be  found  in  our  text-books 
on  salpingitis  will  increase  rapidly,  and  there  will  not  be 
so  many  hundred  pages  on  cellulitis,  displacements,  and 
pessaries. 

Etiology. — Anything  which  causes  endometritis  may 
induce  disease  of  the  Fallopian  tubes,  and  it  is  probable 
that  in  most  cases  salpingitis  is  due  to  an  extension  of 
disease  from  the  lining  membrane  of  the  uterus  directly 
to  that  of  the  tubes.  In  virgins  it  is  comparatively  rare, 
except  from  catarrhal  disease.  In  imperfectly  developed 
and  delicate  girls  and  women,  the  degenerate  state  of  the 
mucous  lining  makes  it  an  easy  prey  to  catarrhal  disease, 
and  an  endometritis  may  be  extended  to  the  tubes.  Tu- 
bercular disease  may  also  attack  the  Fallopian  tubes. 

Many  of  the  profession,  especially  those  who  treat  gen- 
ito -urinary  disease  in  the  male,  look  upon  gonorrhoea  in 
,women  as  a  very  trivial  disease,  probably  because  it  does 
not  produce  urethral  strictures.  When  Dr.  Noeggerath 
read  a  paper  on  this  subject  before  the  American  Gyne- 
cological Society,  in  1876,  his  views  on  gonorrhoea  may 
have  been  extreme,  but  on  salpingitis  they  were  well  in 
advance  of  the  general  knowledge  on  this  subject  at  that 
time,  and  now,  if  the  gonococci  causes  the  disease  and  he 
can  find  the  gonococci  in  all,  or  in  most  of  his  cases  of 
latent  gonorrhoea,  his  theory  will  be  proven  to  be  true. 
There  is  no  doubt  but  that  gonorrhoea  is  a  very  frequent 
and  in  many  instances  an  unsuspected  cause  of  salpin- 
gitis. Among  prostitutes  this  disease  and  septic  endome- 
tritis following  abortions,  by  causing  salpingitis,  accounts 
for  the  incurable  sterility  so  universal  among  this  class, 
even  though  they  return  to  the  paths  of  virtue.  Early  in 
its  course,  before  the  poison  has  reached  the  deep-seated 


glands  of  the  vagina,  or  the  lining  membrane  of  the 
uterus,  it  may  be  checked  in  its  course  by  repeated  ap- 
plications of  a  solution  of  a  mercuric  bichloride  or  some 
other  antiseptic,  but  when  once  it  enters  the  uterus  it 
cannot  safely  be  treated  locally  until  it  has  become  sub- 
acute, for  any  attempt  to  introduce  even  a  small  probe 
may  cause  uterine  contractions  and  pains  which  are  pretty 
certain  to  be  followed  by  local  peritonitis  within  the  next 
twenty-four  hours,  and  the  probability  is,  that  this  is 
caused  by  the  tube  becoming  infected  by  the  contractions 
forcing  the  poison  in  from  the  uterus.  Even  when  treated 
with  the  greatest  care,  specific  endometritis  will  in  many 
instances  cause  salpingitis  and  local  peritonitis.  I  have 
selected  several  well-marked  cases  and  put  them  to  bed, 
and  watched  the  course  of  the  disease  from  the  vagina  to 
the  uterus,  from  the  uterus  to  the  tube  and  peritoneum. 
Salpingitis  from  gonorrhoea  may  result  in  active  pyo-sal- 
pinx  with  a  thick  yellowish  or  greenish  pus,  or  it  may 
become  chronic  and  the  discharge  gleety  and  thin  in  char- 
acter. The  tubes  may  close  at  the  fimbriated  extremity, 
and  after  the  first  attack  of  local  peritonitis  drain  into  the 
uterus,  but  frequently  after  a  time  the  tube  becomes  dis- 
tended on  account  of  a  stricture  of  the  proximal  end,  and 
the  patient  may  have  repeated  attacks  of  local  perito- 
nitis, indicating  that  the  adhesions  which  nearly  always 
seal  up  the  fimbriated  extremity  have  yielded  or  the  poi- 
son in  some  way  has  reached  the  surrounding  tissues. 

Syphilis  may  cause  salpingitis,  just  as  it  does  otitis  or 
oz£ena.  Some  of  the  most  obstinate  cases  of  endome- 
tritis that  I  have  ever  seen  have  been  in  syphilitic  subjects. 

Septic  poisonings  after  labor  and  abortions,  especially 
after  the  latter,  is  a  frequent  cause  of  salpmgitis.  After 
abortions  the  cervix  uteri  is  not  so  patulous  as  after  full 
term  labor,  the  cervix  being  more  irritable  and  likely  to 
contract  and  obstruct  drainage,  and  any  effete  matter  may 
be  not  only  retained  in  the  cavity  of  the  uterus,  but  when 
the  uterus  contracts  it  may  be  forced  into  the  Fallopian 
tubes. 


It  may  be  a  disease  that  induces  the  abortion,  and 
this  extends  to  the  tubes.  Besides,  after  an  abortion, 
neither  the  patient  nor  the  doctor  are  as  likely  to  keep 
up  the  usual  precautions  and  give  time  for  involution  to 
take  place.  Sub-involution  and  endometritis  are  much 
more  common  after  abortions  than  after  normal  labor. 
It  is  my  opinion  that  in  most  instances  it  is  through  the 
tubes  that  septic  poison  causes  local  peritonitis.  Septic 
material  is,  of  course,  often  absorbed  directly  from  the 
uterine  tissues  by  the  blood-vessels  and  lymphatics,  but 
the  poison  is  carried  into  the  circulation,  and  does  not 
directly  enter  the  peritoneal  cavity.  Local  peritonitis  is 
much  more  common  on  the  posterior  surface  of  the  broad 
ligament  than  on  the  anterior  surface,  for  the  tube  opens 
on  the  posterior  surface  of  the  broad  ligament.  IVIy  ex- 
perience leads  me  to  attach  much  more  importance  to 
local  peritonitis  than  local  cellulitis,  for,  except  after 
septiccemia,  where  the  poison  has  become  localized  in  the 
cellular  tissue,  producing  a  phlegmon,  the  cellular  tissue 
is,  as  a  rule,  merely  affected  by  contiguity  with  the  in- 
flamed peritoneal  tissue,  and  I  do  not  believe  in  so-called 
"chronic  cellulitis."  Hydro-salpinx  may  be  due  to 
other  causes  than  venereal  or  catarrhal  disease,  but  in 
what  way  it  has  not  been  made  clear  to  me,  although  1 
must  admit  that  I  have  seen  some  cases  not  satisfactorily 
explained  by  saying  that  it  is  the  sequel  of  catarrhal  dis- 
ease or  subacute  inflammation.  Small  thin  cysts  may  be 
found  on  the  outside  of  the  tube,  but  these  more  properly 
belong  to  the  broad  ligament.  Diseased  tubes  are  very 
commonly  associated  with  diseased  ovaries,  and  I  think 
in  most  instances  the  disease  of  the  tubes  precedes  that 
of  the  ovaries,  and  the  diseased  ovaries  are  but  the  result 
of  an  extension  of  the  disease  from  the  tubes  to  the  ova- 
ries and  peritoneum.  But  certain  diseases  of  the  ovaries 
may  cause  disease  of  the  tubes,  such  as  cancer. 

In  several  cases  I  have  found  cystic  disease  of  the 
ovaries  associated  with  catarrhal  disease  of  the  tubes, 
and  it  is  this  combination  which  I  have  noticed  in  the 


worst  cases  of  hystero-epilepsy.  In  fact,  if  I  have  a  well 
marked  case  of  hystero-epilepsy  or  hysterical  patient  to 
operate  upon,  I  expect  to  find  cystic  or  atrophied  ova- 
ries with  catarrhal  disease  of  the  tubes. 

Hemorrhages  into  the  tube  may  result  in  more  or  less 
permanent  distention,  and  anything  which  stops  up  or 
diminishes  the  size  of  the  lumen  of  the  tube  may  ob- 
struct drainage  and  result  in  disease  and  distention. 

Syjnptoms  and  diagnosis, — The  subjective  symptoms 
are  very  variable.  A  peculiar  burning  pain  over  the  seat 
of  the  tube  affected  is,  perhaps,  more  characteristic  than 
any  other  symptom,  but  many  patients  have  no  such 
pain,  and  local  sensitiveness  and  a  dull  pain  over  the 
tubes  and  ovaries  is  about  the  only  constant  symptom  ; 
sometimes  a  dragging  pain  or  sensation  will  be  present 
when  the  patient  stands,  or  there  will  be  backache  and 
headache,  such  as  is  supposed  to  be  due  to  displacement, 
which  are  so  commonly  associated  with,  and  are  often 
due  to  the  diseased  tubes. 

Dysmenorrhoea  is  a  common  symptom  in  these  cases, 
but  in  some  the  flow  gives  relief  by  lessening  the  conges- 
tion, and  I  am  inclined  to  believe  that  the  pain  is  often 
caused  by  the  endometritis,  or  the  result  of  the  endome- 
tritis in  producing  contraction  and  hypersesthesia  of  the 
mucous  membrane,  for  in  those  cases  where  all  stenosis 
and  endometritis  is  cured  by  treatment,  as  a  rule,  the 
dismenorrhoea  disappears.  Menorrhagia  or  metrorrhagia 
is  often  associated  with  salpingitis,  but  I  think  it  will  most 
frequently  be  found  to  be  due  to  vascular  changes  in  the 
lining  membrane  of  the  uterus,  and  a  thorough  curetting 
with  a  good  instrument  may  effect  a  cure,  although  great 
care  must  be  exercised  in  preparing  the  case  for  opera- 
tion lest  the  salpingitis  be  so  disturbed  as  to  start  up 
peritonitis. 

Sterility  is  the  rule  in  salpingitis,  and  when  both  tubes 
are  affected,  which  is  usually  the  case,  it  is  incurable, 
but  when  only  one  side  is  affected  and  the  proximal  end 
of  the  tube  of  the  diseased  side  is  closed,  pregnancy  is 


possible  and  may  go  to  full  term,  but  as  the  uterus  en- 
larges there  may  be  severe  local  pain,  and  abortion  is 
likely  to  occur. 

Perhaps  the  most  reliable  indication  of  severe  salpin- 
gitis is  the  occurrence  of  repeated  attacks  of  local  peri- 
tonitis, or  active  pelvic  congestion  without  other  evident 
good  reasons  for  such  attacks.  Wet  feet  and  exposure 
to  cold  may  be  an  exciting  cause  and  induce  a  catarrhal 
attack,  and  thus  bring  on  endometritis,  etc.,  but  when  ex- 
posure is  followed  by  peritonitis,  I  would  always  look  for 
a  latent  salpingitis  or  some  such  real  cause. 

Objective  symptoms, — In  acute  cases  there  is  usually  so 
much  swelling  and  tenderness  that  about  all  we  can  make 
out  is  a  fulness  or  thickening  of  one  or  both  broad  liga- 
ments, associated  with  more  or  less  fixation  of  the  uterus. 
Take  such  a  case  and  keep  her  in  bed  until  the  painful 
symptoms  completely  subside.     Then  place  thin  pledgets 
of  cotton  saturated  in  pure  glycerine  against  the  cervix 
uteri  two  or  three  times  a  week,  and,  as   the   case   be- 
comes subacute,  add  alum  to  the  glycerine  and  continue 
"the  pledgets  for  from  three  to  eight  weeks,  and  the  in- 
flammatory  products    will    be    so    much    absorbed   or 
stretched  that  the  uterus  will  become  movable,  and  an 
expert  may  be  able  to  define  an  enlarged  tube  or  a  mass 
that  he   can   make   out   to   contain  a  diseased  tube  or 
ovary  more  or  less  prolapsed  and  adherent  in  one  or  both 
broad  hgaments.     In  subacute  cases  a  diagnosis  may  be 
more  easily  made,   but  often    a   doubtful   case   can    be 
cleared  up   by  the    same   treatment   recommended   for 
acute  cases.     A  diagnosis  is  especially  easy  when  only 
one  side  is  affected   and   the  uterus  is   not   retroverted. 
By  the  prolonged  use  of  pledgets  of  cotton,  soaked  in  a 
mixture  of  alum  and  glycerine,  a  distended  tube  can  be 
readily   defined   by    bimanual    examination.  _    Of  course 
much  will  depend  upon  the  thinness  and  laxity  of  the  ab- 
dominal walls,  and  now  and  then  a  case  will  be  found 
that,  to  get  a  clear  diagnosis,  it  is  necessary  to  examine 
the  patient  under  ether.     In  some  cases  the  floor  of  the 


8 

pelvis  is  so  fixed  by  adhesions,  and  there  is  so  much 
venous  congestion  or  enlargement  of  the  pampiniform 
plexus,  especially  of  the  left  side,  that  a  certain  diag- 
nosis cannot  be  made  ;  a  prolapsus  of,  or  adhesions  to 
the  sigmoid  flexure  may  complicate  and  make  a  diag- 
nosis more  difficult.  In  some  cases  of  catarrhal  tubes 
they  are  not  distended,  but  feel  like  a  thin  band  of  ad 
hesions.  The  ovaries  are  apt  to  be  more  or  less  cystic, 
or  are  often  infiltrated  and  enlarged  by  inflammatory 
products,  and  are  nearly  always  prolapsed  with  and 
folded  under  the  tubes  on  either  side. 

Sometimes,  when  the  proximal  end  of  the  tube  is 
patulous,  the  discharge  will  enter  the  uterus,  and  I  have 
seen  one  or  two  cases  where,  from  an  accurate  knowl- 
edge of  the  state  of  the  uterus  and  vagina,  it  could  be 
made  plain  that  the  gleety  discharge  has  come  from  the 
distended  tube  ;  after  cleaning  the  vagina  and  uterus,  fresh 
pus  could  be  made  to  appear  in  the  vagina  by  slowly 
pressing  upon  the  distended  tube.  The  fluid  may  escape 
intermittently  into  the  uterus,  and,  if  irritating,  may  set 
up  each  time  an  acute  endometritis.  Now  and  then  a 
tube  distended  with  fluid  will  empty  a  large  amount  of 
fluid  into  the  uterus  at  once,  which,  for  the  time,  flows 
freely  from  the  vagina,  and  the  tube  will  refill  and  again 
discharge. 

Pathology. — In  the  literature  of  salpingitis  compara- 
tively little  is  to  be  found  in  English  on  the  subject,  and 
until  very  recently  it  was  hardly  mentioned  in  our  text- 
books. We  are  compelled  to  go  to  German  writers, 
where,  as  before  mentioned,  we  will  find  full  and  accurate 
accounts  of  the  pathology.  I  will  not  attempt  here  to 
give  the  microscopical  appearances,  but  to  bring  out 
more  especially  what  may  be  called  the  surgical  pathol- 
ogy. As  has  been  before  stated,  salpingitis  is  nearly  al- 
ways caused  by  the  extension  of  disease  from  the  endo- 
metrium to  the  lining  membrane  of  the  tubes.  Now,  aside 
from  the  diff"erent  character  of  the  mucous  membrane  of 
the  uterus  from  that  lining  the  tube,  the  different  shape, 


size,  and   position   of  the  tubes  from  that  of  the  uterus 
also  makes  a  marked  change  in   the  results  of  the  same 

disease. 

Inflammation  of  the  endometrium  causing  enlargement 
of  the  uterus  may  result  in  displacement,  imperfect  drain- 
age and  parametritis,  but  this  is  not  the  rule ;  besides, 
the  uterus  is  accessible  and  directly  amenable  to  local 
treatment,  while  inflammation  of  the  lining  membrane  of 
the  tube  which  causes  swelling  is  almost^  certain  to  re- 
sult in  prolapse  of  the  tube  and  obstruction  of  the  nat- 
urally small  lumen,  and  thus  cause  imperfect  drainage, 
and  almost  always  induces  peri-salpingitis  on  account  of 
the  open  extremity  emptying  its  contents  into  the  perito- 
neal cavity.  The  tube  cannot  be  directly  treated ;  the 
lumen  cannot  be  dilated,  and  perfect  drainage  secured 
as  in  endometritis.  Hence  salpingitis  nearly  always  be- 
comes chronic,  in  many  instances  lasting  as  long  as  the 

patient. 

The  first  effect  of  disease  reaching  a  tube,  is  to  cause  it 

to  become  engorged  with  blood  ;  as  it  is  loosely  attached 

to  the  upper  border  of  the  broad  hgament,  it  sinks  lower 

in  the  pelvis  covering  or  folding  over  the  ovary,  and  as 

the  beginning  of  salpingitis,  after  labor  or  an  abortion,  is 

so  ofteii  associated  with  an   enlarged  uterus,  this  organ 

sinks  lower,  and  as  the  patient  during  the  acute  stage  is, 

as  a  rule,  on  her   back,  the  fundus    inclines  backward. 

Now,  suppose  the  uterus   is   enlarged,  lying  backward, 

and  the  disease  affecting  the  uterus  extends  to  the  tubes, 

they  swell,  sag  backward  and  downward,  covering  the 

ovaries,  and   as  soon  as  the  discharge   or    the    disease 

reaches   the   peritoneum   through  the   open   end   of  the 

tube  the  peritoneum  becomes  inflamed,  lymph  is  thrown 

out,  gluing  the  difterent  organs  together.     As  the  acute 

stage  subsides,  the  lymph  contracts,  bands  of  adhesion 

dra^v    and   distort  the  organs,  and    the  folded,   twisted, 

and    adherent   broad   ligament   holds  the   uterus  in  its 

backward  displacement.     As  a  rule,  the  peritoneal  tissue 

covering  the  hmdus  is  not  adherent  to  the  tissues  behind 


I 


lO 

the  uterus,  although  this  seems  to  be  the  case  when  an 
examination  per  vaginam  is  made.  The  uterus  may  sink 
lower,  being  drawn  down  by  contraction  of  the  adhesions, 
and  it  may  become  retroflexed  when  the  adhesions  are 
extensive  and  the  contraction  great.  Again,  the  tube 
being  smaller  and  displaced,  the  lumen  is  stopped, 
the  discharge  accumulates,  distends,  and  leaks  into  the 
peritoneal  cavity,  a  fresh  attack  of  peritonitis  sets  in, 
more  lymph  is  ^exuded,  and  as  the  acute  stage  subsides 
the  tubes  and  broad  ligaments  are  rolled  back  and  folded 
in  more  and  more;  as  the  contraction  goes  on,  the  tis- 
sues harden  and  the  tubes  may  form  strong  cords,  which, 
being  adherent  to  the  floor  of  the  pelvis,  fix  the  uterus 
in  its  retroflexed  and  retroverted  position.  Thus  we  have 
cases  of  retroversion  with  adhesions,  and  it  is  the  rolled 
up  ligaments  and  the  tubes  which  fix  the  uterus  back- 
ward ;  and  it  is  the  imbedded  ovary  and  diseased  tube 
in  the  hardened  tissues  of  the  broad  ligament  which 
makes  it  next  to  impossible  to  insert  a  pessary  and  hold 
the  uterus  up  without  causing  pain  and  running  the  risk 
of  bursting  or  tearing  a  tube  distended  with  septic  or 
irritating  fluid.  By  great  patience  and  time,  in  many 
cases  we  can  stretch  the  ligaments,  and  by  force  get  the 
fundus  uteri  into  that  ideal  normal  position,  but  to  keep 
it  there  is  the  rub ;  the  rolled  up  broad  ligaments  won't 
unroll,  and  when  put  on  the  stretch  by  the  uterus  being 
held  up  by  force,  they  soon  begin  to  ache,  inflame,  and 
may  cause  local  peritonitis. 

Now  suppose  only  one  tube  is  aff'ected,  the  retroversion 
will  be  less,  and  if  the  other  side  is  not  aff'ected  the 
uterus  may  be  even  a  little  anteverted,  unless  the  inflamed 
tube  drops  to  the  floor  of  the  pelvis.  If  the  ovary  and 
the  tube  of  the  aff'ected  side  are  prolapsed  and  inflamed, 
as  contraction  takes  place  the  broad  ligament  is  short- 
ened, especially  on  its  lower  side,  and  unless  the  tube  and 
ovary  are  very  much  distended,  so  as  to  displace  the 
uterus  bodily,  the  cervix  is  drawn  to  the  affected  side, 
the  fundus  being  tipped  toward  the  healthy  or  less  affected 


II 

side,  which  is  usually  the  right  side,  and  the  swollen 
ovary  and  tube  may  be  forced  backward  somewhat 
behind  the  uterus.  When  one  side  only  is  affected,  it 
is  usually  the  left ;  the  circulation  on  this  side,  from  the 
formation  of  the  veins  and  the  proximity  of  the  often- 
distended  intestine  to  the  left  broad  ligament,  seems  to 
make  it  more  susceptible  to  congestion,  prolapses,  and 
disease  than  the  right  side.  When  both  tubes  are  in- 
volved, the  left  is  probably  the  first  to  become  affected, 
this,  together  with  the  natural  position  of  the  uterus 
being  that  with  the  fundus  inclining  slightly  to  the  right 
of  the  centre,  accounts  for  the  fact  that  where  both  tubes 
are  affected  and  the  uterus  is  not  retroverted,  the  cervix 
is  drawn  to  the  left  and  the  fundus  to  the  right,  the  left 
ovary  and  tube  being  prolapsed,  and  the  right  usually 
much  less  prolapsed.  In  nuUiparous  women,  especially  in 
those  cases  where  the  uterus  is  anteverted  or  anteflexed, 
and  where  the  disease  is  gradual  in  its  progress,  this 
condition  of  right  lateral  flexion  with  the  fundus  forward 
is  most  likely  to  be  found,  whereas,  after  labor  and  abor- 
tions salpingitis  is  more  frequently  associated  with  retro- 
version. Sometimes  the  prolapsed  tube,  especially  on  the 
left  side,  is  adherent  to  the  sigmoid  flexure  or  to  the 
small  intestine,  and  the  omentum  may  have  slipped  down, 
especially  when  the  uterus  is  retroverted,  and  become 
adherent  over  and  in  front  of  all  the  pelvic  organs, 
when  it  has  been  thickened  and  the  blood-vessels 
greatly  enlarged  by  repeated  attacks  of  local  peritonitis 
or  general  peritonitis.  To  the  inexperienced  it  is  a  for- 
midable barrier ;  years  ago  I  saw  even  Dr.  Sims  close 
the  abdomen  rather  than  run  the  risk  of  going  through  it 
to  reach  the  ovaries  beneath  it.  These  are  the  cases 
where  eminent  men  will  tell  you  that  they  opened  the 
abdomen,  but  could  not  find  the  ovaries  and  tubes, 
therefore  closed  it.  When  describing  the  operation,  I 
think  I  can  make  it  plain  that  by  a  simple  procedure 
this  apron  of  blood-vessels  can  be  safely  removed.  It 
has  enabled  me  to  complete  the  operation  of  removal  in 


12 

even  the  worst  cases.  Where  the  local  peritonitis  is  lim- 
ited, as  the  tubes  open  near  the  ovaries  which  protrude 
through  the  posterior  surface,  the  adhesions  are,  as  a 
rule,  confined  to  the  posterior  layer  of  the  broad  liga- 
ment, this  accounts  for  the  rarity  with  which  the  blad- 
der is  affected  by  the  adhesions.  The  ureters  are  not  un- 
commonly affected  by  the  adhesions,  especially  when  the 
adhesions  are  low  on  the  floor  of  the  pelvis,  and  in  tear- 
ing up  very  old  and  firm  adhesions  the  ureter  may  be 
lifted  up  (on  one  occasion  it  would  have  been  tied  had  I 
not  recognized  it  as  it  was  lifted  up  by  the  operator). 

Now,  as  to  the  tubes  themselves,  in  cases  of  simple 
catarrh,  especially  those  associated  with  cystic  ovaries — a 
combination  which  seems  to  be  the  most  certain  to  pro- 
duce hystero-epilepsy,  hysteria,  and  all  kinds  of  reflex 
disturbances — the  tubes  may  be  very  little  enlarged,  but 
very  vascular  and  adherent,  with  the  lining  membrane  in 
a  mild  catarrhal  state.  Later  in  the  disease,  more  com- 
monly the  tube  is  distended  by  fluid  and  enlarged  from 
the  size  of  a  lead-pencil  to  enormous  dimensions,  with  the 
fimbrice  turned  in  and  the  end  of  the  tube  closed,  or  the 
fimbrice  may  be  spread  out  and  adherent  to  the  surface  of 
the  ovary,  the  latter  acting  as  a  plug  to  the  mouth  of  the 
tube.  The  end  of  the  distended  tube  may  be  adherent  to 
the  side  of  the  pelvis,  or  the  floor  of  the  pelvis,  to  an 
intestine,  or  even  to  the  other  tube.  The  distended 
tube  may  be,  and  when  large  is,  more  or  less  convoluted, 
sometimes  constricted  at  one  or  more  parts,  and  usually 
with  the  outer  end  much  larger  than  the  proximal  end. 
The  fluid  distending  the  tube  may  be  clear,  transparent, 
watery  fluid,  or  milky  or  gleety,  or  thick  greenish  colored 
pus,  or  thin  broken  down  pus.  Ciliated  epithelium  is  the 
chief  microscopical  characteristic  of  the  clear  fluids. 
When  the  tube  is  greatly  distended  and  the  adhesions 
slight,  it  is  usually  a  hydro-salpinx,  but  when  large  with 
many  adhesions  it  is  likely  to  be  pus  that  distends  the 
tube.  In  my  cases,  in  the  majority  of  instances  the  tubes 
were   infiltrated  with   pus  and   serum,  and  degenerated 


13 

rather  than  distended.  In  those  where  abscesses  were 
found  formed  in  the  substance  of  the  ovaries  and  tubes, 
the  tissues  were  so  rotten  that  in  tying  them  off  the 
hgatures  cut  through  the  degenerated  stump,  and  I  was 
compelled  to  pick  up  the  arteries  and  tie  them  one  by 
one.  These  might  fairly  be  called  cases  of  pelvic  abs- 
cesses. In  old  cases  the  tissues  may  have  atrophied  and 
contracted  down  so  that  it  is  difficult  to  remove  all  of 
the  ovary  and  have  a  stump  long  enough  to  hold  the 
ligature.  In  most  cases  the  ovaries  are  covered  with  the 
intiamed  tube  and  shreds  of  adhesions,  and  in  pyo-salpinx 
they  may  be  inflamed  and  filled  with  small  abscesses  or 
infiltrated  with  pus,  and  are  sometimes  so  degenerated 
that  they  are  torn  to  pieces  in  being  removed.  Some- 
times the  interstitial  tissue  of  the  ovary  is  affected,  and 
may  be  hardened  and  contracted,  or  the  ovary  may  be 
found  abnormally  small  and  atrophied,  but  the  most 
common  condition  of  the  ovaries,  if  affected  by  an  inde- 
pendent disease  at  all,  is  that  of  cystic  degeneration  ; 
usually  the  cysts  are  numerous — small  ones  filled  with  a 
gummy,  translucent  fluid.  Superficial  cysts  with  thin  fluid 
are  very  commonly  found,  but  deep-seated  central  cysts 
may  fairly  be  called  cystic  degeneration,  and  it  is  to  this 
class  I  refer  when  speaking  of  cystic  degeneration  of  the 
ovaries. 

In  some  cases,  the  cellular  tissue  may  be  infiltrated 
and  thickened  by  lymph,  but  the  preparatory  treatment 
almost  always,  more  or  less,  completely  removes  this 
lymph,  and  the  real  adhesions  that  bind  and  twist  the 
organs  out  of  place  will  be  found  to  be  peritoneal. 

Prevention. — When  the  etiology  of  any  disease  is  well 
understood  the  prevention  is  plainly  indicated.  It  is  im- 
portant that  the  general  health  and  strength  of  girls  while 
developing  into  women  should  be  kept  up,  so  that  the 
generative  organs  will  fully  develop  and  resist  catarrhal 
disease.  When  there  are  symptoms  of  catarrhal  disease, 
such  as  leucorrhosa  and  dysmenorrhoea  they  should  be 
treated  early,  before  it  has  reached  the  Fallopian  tubes, 


14 

and  if  the  endometrium  is  affected  by  disease  the  uterine 
canal  should  be  kept  patulous  so  as  secure  perfect  drain- 
age, and  thus  lessen  the  chance  of  the  disease  entering 
the  Fallopian  tubes.  The  serious  nature  and  the  almost 
certain  consequences  of  venereal  diseases  should  be  ex- 
plained to  and  impressed  upon  all  young  persons,  and 
definite  instructions  should  be  given,  especially  to  all 
male  patients  suffering  with  gonorrhoea,  to  avoid  inter- 
course until  complete  cure  is  affected.  No  doubt  many 
of  the  cases  supposed  to  be  due  to  septic  poisons  after 
labor  are  really  caused  by  gonorrhoea  contracted  from 
husbands  who  have  been  led  astray  while  deprived  of 
their  usual  indulgence  during  the  confinement  of  their 
wives.  The  serious  consequences  of  even  a  slight  septic 
endometritis  in  causing  a  salpingitis  makes  more  forcible 
the  great  importance  of  cleanliness  and  the  use  of  anti- 
septics or  any  other  means  that  may  lessen  the  chance  of 
puerperal  septicjemia.  We  know  that  subinvolution  rarely 
exists  without,  sooner  or  later,  the  development  of  endo- 
metritis, and  instead  of  taking  it  for  granted  that  when  a 
woman  has  passed  the  ninth  day  after  labor  that  the  doc- 
tor's responsibility  in  the  case  is  at  an  end,  every  lying-in 
woman  should  be  examined  locally  before  she  is  allowed 
to  go  about  her  usual  duties,  and  it  is  safer  to  keep  the 
woman  under  observation  until  the  uterus  is  normal  in 
size,  position,  and  condition,  before  dismissing  her.  If 
treatment  is  needed,  it  is  better  to  begin  it  not  later  than 
the  end  of  the  second  week  after  labor.  A  few  stimulat- 
ing applications  of  glycerine  and  alum  made  twice  a  week 
during  the  third,  fourth,  fifth,  and  sixth  week  after  labor 
will  prevent  subinvolution,  retroversion,  endometritis,  and 
a  salpingitis  in  a  delicate  or  weak  woman  that  without  it 
would  be  pretty  certain  to  be  affected  with  one  or  more 
of  these  serious  affections. 

When  \YQ  have  an  endometritis  it  is  especially  impor- 
tant that  we  should  secure  perfect  drainage  from  the 
uterus.  After  abortions  the  greatest  care  should  be  taken 
to  prevent  septic  infection  a.nd  insure  removal  of  all  the 


15 

placenta  and  membranes.  p:special  care  should  be  taken 
to  secure  perfect  involution  and  dramage  of  the  uterus, 
for  after  labor  nature  generally  accomplishes  this  without 
help  but  not  so  in  abortions.  Labor  is  normal,  but  abor- 
tions are  abnormal,  and  must  be  regarded  as  almost  certain 
to  result  in  disease. 

treatment.— \)v\xm%  the  acute   stage  complete  rest  in 
bed  is  the  best  treatment ;  anodynes  and  counter-irritants 
may  be  used;  as  the   active  symptoms   subside,  I  begin 
the  application  of  thin  pledgets  of  cotton  saturated  in  pure 
glycerine  and  applied  to  the  cervix  and  vagina  ;  they  are 
left  in  place  twenty-four  hours,  then  removed  and  a  douche 
of  hot  water  given ;  on  the  third  day  another  pledget  is  put 
in,  and  this  is  kept  up  for  a  week  or  two  •  and  later  a  so- 
lution of  one  part  of  boro  glyceride,  one  of  alum,  and  four- 
teen of  pure  glycerine  is  used  to  saturate  the  cotton  in 
place  of  pure  glycerine.    After  a   week  or  so  this  softens 
out  the  products  of  inflammation  and  renders  the  uterus 
more  movable,  and  enables  one  to  make  a  more  accurate 
diagnosis.     It  improves  the  circulation,  and  often  gives 
for  the  time,  more  or  less  complete  relief  to  all  the  local 
symptoms.     V/hile   this  simple  local  treatment  is  given 
close  attention  should  be  paid  to  the  general  health,  and 
the   condition    of  digestion,   and  especially  the    bowels, 
should  be  carefully  regulated,  for  impacted  fecal  matter 
in  the  lower  end  of  the  descending  colon  or  rectum  may 
materially  add  to  the  pain  and  the  effects  of  the  disease 
by  pressing' directly  on  the  left  broad  ligament. 

After  fretting  the  uterus  movable,  so  that  it  can  be 
pulled  pretty  well  down  with  the  tenaculum  without 
causing  much  pain,  it  will  be  safe  to  sound  the  uterus, 
and  if  the  canal  is  contracted  and  hyperc^sthetic,  it 
should  be  gently  dilated  so  as  to  secure  good  drainage 
and  enable  applications  to  be  made  to  the  mucous  hmng. 
If  there  is  a  history  of  excessive  hemorrhage,  and  it  is  not 
corrected  by  tincture  cannabis  indica,  twenty  gtts.  given 
twice  a  day,  if  the  uterus  can  be  gotten  movable  by  the 
use  of  the  medicated  pledgets,  it  will  be  safe  to  curette 


i6 

the  uterus  for  the  removal  of  granulations.  I  would  al- 
ways give  the  above  treatment  as  preparatory  to  opera- 
tion, except  in  those  cases  where  the  diagnosis  was  plain 
and  indicated  immediate  action  to  prevent  rupture  of  a 
painful  cyst,  or  to  prevent  septic  poison  and  death  after 
rupture.  In  these  cases  I  would  resort  at  once  to  the 
operation  for  removal.  Aspiration  through  either  the 
abdominal  wall  or  vagina  can  give  only  temporary  relief 
by  evacuating  the  contents  of  a  cystic  tube  or  ovary,  but 
there  is  some  risk  and  little  or  no  permanent  good  at- 
tained. Where  a  large  amount  of  pus  had  accumulated 
in  three  cases,  and  abdominal  section  would  not  be  per- 
mitted, I  have  resorted  to  a  simple  method  of  opening 
and  draining.  With  a  long  and  curved  trocar  I  punct- 
ured the  walls  of  the  abscess,  being  careful  to  pass  the  tro- 
car directly  behind  the  cervix  so  as  to  avoid  large  blood- 
vessels and  the  ureters.  After  passing  the  trocar  the  canula 
was  withdrawn  and  the  pus  evacuated,  and  the  cavity  re- 
peatedly washed  out  with  solution  i  to  5,000  mrc.  bichl. 
With  canula  still  in  place,  I  turned  patient  on  her  side  in 
Sims'  position,  and  introduced  Sims'  speculum  in  the  va- 
gina ;  then  I  passed  through  the  canula  a  small  probe 
without  a  handle,  and  slipped  the  canula  out  over  the 
probe,  using  the  probe  as  a  guide  ;  with  Sims'  uterine 
dilator  I  dilated  the  opening  so  that  I  could  pass  my 
finger  into  the  abscess.  By  means  of  a  pair  of  slender 
forceps  I  carried  into  the  abscess  a  large-sized  drainage 
tube  of  soft  rubber ;  in  this  way  I  avoided  the  use  of  a 
knife  and  the  risk  of  cutting  a  blood-vessel  or  the  ureter. 
To  prevent  the  tube  from  slipping  or  being  forced  out  as 
the  cavity  of  the  abscess  contracts  I  passed  a  silver  su- 
ture through  the  posterior  lip  of  the  cervix  and  the  wall 
of  the  drainage-tube  and  tied  the  tube  to  the  cervix. 
The  cavity  was  washed  out  with  an  antiseptic  solution  as 
was  indicated  by  the  discharge  and  temperature  of  the 
patient ;  as  the  discharge  diminished,  the  large  tube  was 
replaced  by  a  smaller  one,  and  the  opening  kept  dilated 
until  all  drainage  ceased. 


17 

One  of  the  three  cases  seemed  to  be  permanently 
cured  and  all  were  helped,  but  1  would  not  advise  this 
treatment,  except  in  those  cases  where  abdominal  section 
is  not  allowed,  or  where  there  seems  to  be  only  one  large 
cyst,  such  as  is  sometimes  found  following  a  broken-down 
ha^matocele.  In  most  cases  the  abscess  or  distended 
tube  is  too  small  to  be  reached  safely  in  this  way.  If, 
after  opening  the  abdomen  and  finding  a  large  pus  cav- 
ity, I  wished  to  make  a  counter-opening  through  the 
vagina,  I  would  make  a  small  opening  with  a  trocar  and 
then  dilate  it  with  dilators.  In  case  of  a  large  pelvic 
abscess  pointing  toward  Poupart's  ligament,  I  would 
open  by  an  incision  in  the  groin  and  would  not  enter  the 
peritoneal  cavity  above  the  abscess,  except  to  secure 
complete  removal  or  to  get  perfect  drainage. 

When  diseased  tubes  are  plainly  made  out  and  the 
patient  is  bedridden,  or  suffers  to  such  an  extent  that 
after  being  clearly  informed  as  to  the  effect  and  danger 
of  the  operation  and  consents,  then  we  consider  com- 
plete removal  of  both  tubes  and  ovaries,  if  both  sides  are 
affected,  to  be  justifiable.  By  softening  the  indurated 
tissue  and  improving  the  circulation  of  the  pelvis  we  can 
help  but  not  cure.  By  atrophy  and  absorption  nature 
may  cure,  but  chronic  invalidism  usually  comes  before 
nature  has  effected  a  cure.  Or,  by  the  bursting  of  a  dis- 
tended tube,  general  peritonitis  and  death  may  follow 
instead  of  the  usual  attack  of  local  peritonitis.  Many  a 
case  of  so-called  idiopathic  peritonitis  has  been  caused 
by  the  bursting  of  a  diseased  Fallopian  tube,  and  the  pa- 
tient might  have  been  saved  by  a  bold  surgeon  even 
after  the  peritonitis  set  in. 

Operation  for  removal— I  ^o  not  expect  to  improve 
upon  Mr.  Tait's  work  as  an  operator,  but  I  think  I  can 
make  the  operation  easier  to  others  by  describing  a 
methodical  way  of  doing  the  operation  for  removal  of  the 
tubes  and  ovaries,  in  cases  where  the  adhesions  are  ex- 
tensive. 

After  giving  the  preparatory  treatment  with  glycerine 


i8 

and  alum  pledgets  as  described,  and  having  decided  that 
an  operation  is  proper,  I  have  the  patient's  bowels  well 
emptied  and  put  her  on  pancreatized  milk  diet  with  very 
little  other  plain  food  for  three  or  four  days  previous  to 
the  operation,  the  object  being  to  remove- all  impacted 
fecal  matter,  and  to  lessen  the  amount  of  gas  in  the  in- 
testines, for  the  latter  may  be  very  troublesome  by  crowd- 
ing down  around  the  pelvic  organs  and  out  through  the 
incision  in  the  abdominal  wall  during  the  operation. 
When  well  prepared,  there  will  be  little  or  no  gas  in  the 
intestines,  and  they  will  be  found  to  be  like  so  many 
slippery  ribbons.  The  day  of  the  operation  the  bowels 
should  be  well  moved,  but  not  excessively. 

In  all  surgical  practice  I  would  place  cleanliness  first, 
drainage  second,  rest  third,  and  antiseptics  fourth.  If 
we  could  be  perfect  in  cleanliness,  antiseptics  would  be 
useless.  Some  of  us  are  willing  to  be  considered  fallible 
and  use  antiseptics  to  make  up  for  it.  Before  Lister 
made  perfectly  plain  the  -necessity  of  cleanliness  and 
proved  the  value  of  antiseptics,  not  many  of  us  were  so 
particular  about  cleanliness,  nor  did  we  know  how  im- 
portant it  was  to  success  in  surgery.  Cleanliness  is 
better  than  antiseptics,  just  as  prevention  is  better  than 
cure.  Before  Lister's  teachings,  what  surgeon  spent 
hours  in  cleaning  instruments  and  sponges,  and  placed 
over  wounds  a  thick  layer  of  absorbent  cotton-wool? 
Cotton-wool  is  known  to  be  the  best  thing  to  prevent  the 
passage  of  germs  and  their  spores,  and  he  who  uses  it 
for  dressing  wounds  carries  out  the  principles  taught  by 
Lister. 

Before  operating,  my  patient  is  thoroughly  bathed  and 
clean  clothing  for  her  body  and  bed  ordered  ;  just  before 
being  etherized,  one- quarter  to  one-third  of  a  grain  of 
morphine  is  given  hypodermically.  When  under  ether, 
the  abdomen  is  shaved  well  down  to  the  pubic  bone,  and 
thoroughly  washed  with  soap  and  water,  and  before  the 
skin  is  cut,  again  well  washed  with  a  solution  of  one  to 
five  thousand  of  mercuric  bichloride.     Instruments  are 


19 

all  kept  in  solutions  of  one  to  twenty  No.  i  Calvert's 
acid,  carbol.,  and  sponges  in  a  solution  of  one  to  ten 
thousand  of  mercuric  bichloride.  Besides  the  operator 
only  four  assistants  are  needed:  one  to  give  ether,  one 
to  handle  instruments,  one  to  clean  sponges,  and  one 
to  stand  opposite  the  operator  and  sponge.  Ordinarily 
the  man  to  hand  instruments  can  be  dispensed  with, 
and  I  do  not  use  any  one  for  this  purpose  except  in 
my  hospital  clinics,  for  of  course  the  number  of  persons 
helping  adds  to  the  danger  of  infection.  All  assistants 
are  required  to  wash  as  clean  as  possible,  and  use  solu- 
tion oT  bicliloride  afterward. 

In  putting  the  patient  on  the  operating  table,  I  place  a 
soft  pillow  under  the  shoulders  and  one  under  the  head, 
and  have  the  feet  so  fixed  as  to  keep  the  knees  about 
level  with  the  abdomen.  This  relaxes  the  abdominal 
wall  to  some  extent.  The  bladder  is  emptied,  and  the 
abdominal  incision  is  made  just  above  the  pubes.  The 
length  of  incision  in  the  skin  being  from  two  and  one- 
half  to  three  inches,  according  to  the  amount  of  fat  in  the 
abdominal  walls,  the  opening  in  the  peritoneum  being 
only  large  enough  to  allow  the  free  use  of  my  index  and 
middle  fingers  at  the  same  time.  This  opening  is  rarely 
made  larger,  unless  the  size  of  the  distended  tube  or 
ovary  makes  it  absolutely  necessary  in  extracting  them. 
A  larger  opening  is  avoided,  because  it  adds  to  the  risk 
of  septic  poisoning,  and  makes  ventral  hernia  more  likely 
to  follow.  When  ovarian  and  other  large  tumors  are  re- 
moved, the  abdominal  walls  are  relaxed,  and  there  is 
less  tension  on  the  sutures  and  perfect  union  is  more 
readily  secured  than  in  those  cases  where  the  abdominal 
pressure  is  normal. 

When  the  subperitoneal  fat  is  reached,  it  maybe  trou- 
blesome to  get  through  it,  for  there  is  no  distended  tumor 
directly  underneath  it  to  keep  away  intestines  and  hold 
the  many  layers  of  the  peritoneum  together,  and  where 
gas  is  in  the  intestines  this  diflficulty  is  increased.  Where 
the  omentum  is  free  from  adhesion,  it  can  be  pushed  up 


20 

as  one  would  the  end  of  an  apron.  When  it  is  adherent, 
as  it  often  is,  to  the  broad  ligament  and  anterior  wall  or 
top  of  the  uterus,  it  cannot  easily  be  separated  by  pulling 
it  from  below  upwards,  but  by  passing  the  two  fingers 
well  to  one  side  and  getting  them  underneath,  and  sep- 
arating the  adhesions,  many  formidable  looking  cases  can 
be  easily  managed.  As  the  adhesions  separate,  they 
should  be  lifted  through  the .  opening  and  any  bleeding 
points  tied.  The  principal  vessels  in  adhesions  of  the 
omentum  come  from  those  of  the  omentum,  and  not  from 
the  pelvic  organ  ;  therefore,  the  end  of  the  omentum  is  the 
part  to  be  tied.  If  the  adhesions  are  strong  and  vascu- 
lar, as  they  may  be  in  those  cases  where  there  have  been 
repeated  attacks  of  local  peritonitis,  then  the  omental 
adhesion  can  be  tied  off,  tied  first  as  low  as  possible,  and 
then  a  little  above  this,  and  cut  between  the  ligatures.  By 
pulling  the  sides  of  the  abdominal  opening  laterally  with 
retractors,  we  can  do  this  without  enlarging  the  opening 
in  most  cases.  In  handling  and  tying  the  omentum, 
care  should  be  taken  not  to  split  or  tear  it,  for  it  will  in- 
variably bleed  up  in  the  angle  of  the  split,  and  may  be 
very  troublesome.  Where  the  uterus  is  retroverted,  the 
removal  of  the  omentum,  as  a  rule,  frees  the  anterior 
part  of  the  fundus  and  the  anterior  face  of  the  broad  lig- 
aments ;  often  the  small  intestines  will  have  to  be  sep- 
arated, but  are  not  often  firmly  adherent.  The  next 
step  is  to  elevate  the  uterus  by  placing  the  fingers  be- 
hind it.  The  back  of  the  fundus  may  be  adherent,  but, 
as  a  rule,  it  is  free  and  is  held  back  by  the  twisted  and 
rolled  up  state  of  the  broad  ligaments.  The  ovary  will 
be  found  folded  under  the  tube  and  broad  ligament,  and 
to  get  it  up  we  must  go  down  through  the  broad  liga- 
ment, or  we  must  unroll  the  broad  ligament.  I  have 
seen  the  former  done  several  times,  and  it  always  adds 
greatly  to  the  length  of  the  operation,  and  necessitates 
tearing  or  tying  off  the  outer  attachments  of  the  broad 
ligament  before  the  tube  can  be  gotten  up  and  tied  off 
with  the  ovary.     Now,  by  putting  both  fingers  directly 


21 

down  behind  the  uterus,  and  running  the  fingers  later- 
ally, guided  by  the  Fallopian  tubes,  as  it  is  given  off  from 
the  uterus,  and  gradually  sei)arating  the  adhesions  and 
unrolling  till  we  get  under  the  ovary,  the  tube  and  ovary 
can  be  gotten  up  easily  in  the  worst  cases ;  where  the 
adhesions  are  very  firm,  an  assistant's  finger  in  the  va- 
gina as  a  guide  may  be  useful,  for  in  scratching  loose  the 
adhesions  the  ureter  may  be  lifted  up,  and  the  sigmoid 
flexure  or  rectum  may  be  torn  up,  for  it  maybe  adherent 
to  the  tube  or  ovary  on  the  left  side.  When  both  sides 
are  adherent  it  may  be  well  to  lift  up  both  sides  before 
tying  either ;  although  in  some  cases,  where  the  bleeding 
is  free,  it  may  be  better  to  tie  the  first  one  lifted  up.  In 
three  cases  I  found  the  tissues  so  degenerated  that  my 
ligature  cut  through,  and  compelled  me  to  slightly  enlarge 
the  abdominal  opening  and  tie  the  arteries  after  pick- 
ing them  up  with  a  bull-dog  forceps.  Where  the  tissues 
are  frail  and  ligatures  inclined  to  cut  easily,  it  is  safer  to 
remove  the  tissues  and  tie  the  arteries  separately.  Two 
or  three  arteries  will  usually  be  found.  Where  the  broad 
ligament  is  much  enlarged,  we  may  tie  with  two  ligatures, 
one  double  ligature  including  the  ovarian  ligament  and 
the  tube  within  half  an  inch  of  the  fundus,  the  other 
single  and  tying  off  the  outer  end  of  the  broad  ligament. 
The  pampiniform  plexus  may  give  trouble,  but  I  have 
seen  it  so  degenerated  as  to  pull  to  pieces  in  being  tied. 
I  use  firmly  twisted  Chinese  silk,  and  prefer  to  pass  the 
ligature  with  a  needle  something  like  an  aneurism  needle, 
with  a  sharper  point  and  longer  handle  than  those  found 
in  the  shops,  to  carry  a  double  thread. 

In  tying,  except  in  cases  where  one  double  ligature 
will  suffice,  I  do  not  use  Mr.  Tait's  Staftbrdshire  knot, 
but  I  cross  and  interlock  the  two  loops  of  all  my  double 
ligatures,  and  so  far  I  have  never  had  a  ligature  slip  after 
the  operation.  After  tying,  before  cutting  oft'  the  tube 
and  ovary,  I  catch  the  tissue  with  pressure-forceps  close 
to  the  ligature,  so  that  I  can  cut  off  my  ligatures  and 
not  be  tempted  to  use  them  to  lift  up  the  pedicle  after 


22 

being  once  tied.  Besides  enabling  me  to  keep  the  pedicle 
in  sight,  these  forceps  act  as  guides  in  cutting  away  the 
tube  and  ovary.  Often  the  ovarian  ligament  is  so  short 
that  it  is  not  easy  to  get  a  satisfactory  stump  left  and  cut 
off  all  the  ovary.  I  like  to  have  a  Paquelin  cautery  on 
hand,  so  as  to  touch  any  suppurating  end  of  a  tube  in  a 
stump  or  ovarian  tissue  that  may  be  left  on  it  after  tying. 
The  tubes  and  ovaries  of  both  sides  should  be  removed 
if  there  is  the  least  sign  of  salpingitis  ;  but  in  two  cases 
I  found  only  the  left  side  affected,  the  right  tube  and 
ovary  being  free  from  even  a  single  adhesion,  and  I  re- 
moved only  those  of  the  diseased  side. 

The  cavity  should  be  thoroughly  dried  with  sponges 
and  time  given  for  hemorrhage  to  make  itself  manifest 
before  the  wound  is  closed.  Where  there  are  extensive 
adhesions  or  any  pus  cavity  disturbed,  or  especially  where 
there  is  any  ascites,  a  drainage-tube  should  be  put  into 
the  pelvic  cavity.  I  prefer  a  large-sized  tube  of  glass 
with  some  small  holes  in  the  sides  besides  the  ends  be- 
ing open,  and  I  use  a  large-sized  catheter  attached  to  an 
ordinary  syringe  for  washing  out  the  tube  when  needed. 
If  there  is  no  drainage  I  remove  the  large  tube  in  thirty- 
six  hours  and  slip  a  small  rubber  drainage-tube  in  its 
place,  and  the  next  day  a  still  shorter  and  smaller  one, 
each  day  until  about  the  seventh  day,  when  the  opening 
will  usually  be  filled  up  from  the  bottom.  In  introducing 
the  sutures  in  the  abdominal  wall,  I  am  careful  to  secure 
not  only  perfect  coaptation  of  the  peritoneal  coats,  but 
also  of  the  deep  and  thick  abdominal  fascia,  for  if  good 
union  of  this  is  secured  the  risk  of  ventral  hernia  is  very 
much  lessened  ;  for  it  is  this  tissue  and  not  the  muscles, 
which  are  longitudinal,  that  gives  strength  to  the  abdom- 
inal wall  in  the  median  Hne.  For  thirty-six  to  forty-eight 
hours  nothing  is  allowed  to  be  taken  except  teaspoonful 
doses  of  water  or  broken  ice,  and  enough  morphine  is 
used  to  prevent  pain  and  restlessness,  for  several  days. 
An  enema  is  usually  given  on  the  sixth  day  to  move  the 
bowels,   and    sutures    are  removed  on  the   eighth    day. 


23 

Either  medium  silk  or  silver  wire  is  used  in  sutures  for 
the  abdominal  walls. 

If  the  abdominal  walls  are  thick  from  adipose  tissue, 
as  a  rule,  the  peritoneum  will  be  found  tense,  and  require 
more  than  usual  care  in  closmg  properly.  In  such  a  case, 
after  jnitting  in  from  three  to  six  silk  sutures  through  the 
skin,  fascia  lata  and  peritoneum,  the  peritoneum  should 
be  carefully  closed  with  catgut  sutures,  and  the  fascia  lata 
also  separately  closed  in  the  same  way.  Then  the  first 
silk  sutures  should  be  closed,  leaving  room  between  them, 
in  two  or  more  spaces,  for  short  drainage-tubes  placed 
upright  so  as  to  drain  the  adipose  tissue  between  the 
fascia  and  the  skin.  Or  if  the  walls  are  closed  by  silk 
sutures  in  the  usual  way,  the  skin,  a  little  to  the  side  of 
the  cut,  should  be  punctured  so  as  to  give  vent  to  the 
grease  that  is  certain  to  escape  from  the  more  or  less 
bruised  adipose  tissue.  I  have  seen  mural  abscess 
caused  by  this  free  fat,  and  it  might  enter  the  peritoneum 
and  cause  greater  trouble.  After  sewing  up  and  clean- 
ing the  wound,  it  should  be  freely  sprinkled  with  iodo- 
form and  covered  with  a  layer  of  absorbent  cotton  that  has 
been  squeezed  out  in  one  to  five  thousand  mercuric  bi- 
chloride, and  over  this  several  layers  more  of  dry  absor- 
bent cotton,  so  that  the  whole  abdomen  will  be  evenly 
compressed  when  the  adhesive  straps  and  band  are  put 
on.  Over  the  cotton  a  folded  towel  and  mackintosh  are 
placed,  and  firmly  compressed  by  adhesive  straps  and  a 
bandage.  Except  where  a  drainage-tube  is  inserted,  this 
dressing  can  remain  until  the  eighth  or  ninth  day,  when 
the  sutures  are  removed,  unless  oozing  appears  through 
the  dressing,  or  a  rise  of  temperature  takes  place  indi- 
cating septic  poisoning,  etc.  In  cases  with  extensive  ad- 
hesions or  in  pyo-salpinx,  especially  where  the  tissues  are 
infiltrated,  we  must  expect  a  moderate  rise  of  temperature 
during  the  first  two  or  three  days,  caused  by  the  small 
amount  of  septic  material  left  in  the  pelvis  ;  but  this  is 
readily  absorbed  and  the  local  peritonitis  caused  by  it 
soon  subsides,  and  on  the  fourth  or  fifth  day  the  tempera- 


24 

ture  falls.  When  the  case  fails  to  rally  well,  and  has  a 
temperature  at  or  below  normal,  or  in  some  cases  where 
all  symp'toms  are  favorable  and  temperatm'e  low  until 
the  afternoon  of  the  third  or  on  the  fourth  day,  the  tem- 
perature makes  a  steady  rise,  you  have,  as  a  rule,  a  fatal 
case  of  septicaemia  to  deal  with,  that  death  alone  will 
stop — which  it  usually  does  inside  of  two  or  three  days. 
Sometimes  a  case  begins  as  a  local  peritonitis  and  gradu- 
ally spreads  to  general  peritonitis,  vomiting,  and  death. 
Still,  I  think  the  proper  name  for  such  a  case  is  septi- 
caemia. 

Coinplicatio7is. — As  endometritis  nearly  always  precedes 
salpingitis,  it  is  necessarily  a  frequent  complication.  It  is 
rare  to  find  salpingitis  uncomphcated  by  local  peritoni- 
tis, and  this,  by  the  formation  and  contraction  of  bands  of 
adhesions,  distorts  and  displaces  the  pelvic  organs  and 
makes  more  or  less  permanent  any  displacement  that 
may  have  previously  existed.  This  was  fully  brought  out 
in  describing  the  treatment.  The  most  serious  and  dan- 
gerous complication  is  the  rupture  of  a  tube  distended 
with  septic  fluid,  causing  general  peritonitis  and  septi- 
caemia. Should  this  happen  and  be  diagnosed,  or  be  in- 
dicated as  the  probable  cause  of  peritonitis,  it  would  be 
proper  to  open  the  abdominal  cavity,  remove  the 
tube,  and  wash  out  and  drain  the  peritoneum.  The  in- 
flammatory process  may  become  so  intense  in  or  about  the 
tube  as  to  cause  the  tissues  to  break  down,  and  form  so 
large  an  abscess  that  the  surrounding  tissues  lose  the 
power  to  protect  themselves,  and  a  perforation  takes 
place  into  the  rectum,  vagina,  abdominal  wall,  or  through 
one  of  the  openings  in  the  pelvis,  or  into  the  bladder. 
This  necessitates  enlarging  the  opening  to  secure  drain- 
age, and  often  before  a  cure  can  be  effected  counter- 
openings  are  necessary,  and  if  these  fail,  an  operation  for 
removal  must  be  resorted  to. 


NEW   YORK   ACADEMY    OF   MEDICINE. 
Annual  Meetings  January  15,  1885./ 

FoRDYCE  Barker,   M.D.,  LE.D.,   President,  in  the 

Chair. 

Dr.  W.  Gill  Wylie  read  a  paper  entitled, 

diseases  of  the  fallopian  tubes  :  their  relations 
TO  uterine  displacements  and  the  use  of  pes- 
saries. 

Dr.  E.  Noeggerath  was  invited  to  open  the  discus- 
sion, and  said  that  he  had  listened  with  a  great  deal  of 
pleasure  to  the  scientific  and  practical  paper  of  the  even- 
ing, and  that  while  there  were  very  many  difficulties  and  a 
great  variety  of  opinion  concerning  the  investigation  of 
this  class  of  cases,  he  would  only  direct  attention  to  a 
few  points  which  were  still  the  subject  of  discussion. 

First,  he  would  repeat  what  had  already  been  stated 
at  the  International  Medical  Congress  of  Copenhagen, 
that  it  was  a  misnomer  to  call  the  operation  ''  Tait's 
operation."  Hegar,  in  September,  1879,  reported  forty- 
two  cases  in  which  this  operation  was  performed,  with  or 
without  the  removal  of  the  tubes  and  performed  to  meet 
the  same  indications.  Therefore,  if  Tait  was  to  receive 
any  mention  in  connection  with  the  operation,  it  should 
be  simply  as  to  the  number  of  cases  in  which  he  had 
operated. 

Dr.  Wylie  had  asked  whether  always  in   cases  of  sal- 
pingitis   the    disease   was    caused    by  gonorrhoea.     Dr. 
Noeggerath   had  investigated   this    subject,    and    made 
special  researches  in  this   direction  for  the  purpose  of 
2 


26. 

demonstrating  the  presence  of  the  gonococcus.  Now, 
the  gonococcus  is  a  diplococcus,  and  of  these  four 
different  species  had  been  described  as  existing  in  the 
vagina.  As  yet,  however,  we  had  not  been  able  to  ob- 
tain a  gelatine  in  which  the  gonococcus  could  be  cul- 
tivated. Dr.  Noeggerath  had  already  tried  four  different 
kinds  of  gelatine  and  had  had  not  yet  been  satisfied 
with  the  results— the  microbes  obtained  by  culture  did 
not  resemble  the  original  ones.  He  had  also  com- 
j)ounded  a  coloring  material  which  stained  the  gonococcus 
a  peculiar  red  color,  and  the  other  tissues  of  a  different 
color,  but  he  had  failed  in  this  respect,  because,  as  he 
now  believed,  in  the  uterus  after  a  certain  time — say  six, 
eight,  or  ten  weeks — if  there  be  gonococci  they  exist  in 
such  small  numbers  that  the  micro-organisms  can  be 
demonstrated  only  by  culture  in  gelatine,  which  as  yet  he 
had  not  succeeded  in  doing. 

He  could  not  say,  therefore,  whether  the  secretion  of 
gonorrhoea  in  its  chronic  state  was  simply  the  result  of  a 
paralytic  condition  of  blood-vessels,  originally  produced 
by  the  gonococcus,  or  whether  the  gonococcus  still 
existed  in  small  quantities,  producing  emigration  of 
leucocytes.  The  demonstration  of  the  gonorrhoeal  origin 
rested  as  yet  only  upon  clinical  facts. 

As  to  the  connection  between  salpingitis,  perimetritis, 
and  uterine  dislocation,  if  there  was  anything  which  was 
characteristic  of  salpingitis  and  perimetritis,  it  was 
lateral  version  combined  with  anteversion. 

He  did  not  doubt  that  Dr.  Wylie  had  seen  retroversion 
with  pyosalpinx,  as  there  were  probablj'"  such  severe 
cases,  but  they  were  the  exceptions. 

It  there  existed  nothing  else  upon  which  to  make  a 
diagnosis  of  salpingitis,  the  fact  that  there  was  diminished 
mobility  of  the  uterus,  with  anteversion,  or  with  light 
lateral  version,  and  a  certain  form  of  uterine  catarrh,  was 
sufficient.  Furthermore,  with  regard  to  retroversion,  he 
was  well  aware  that,  eight  or  ten  years  ago,  a  certain 
number  of  gynecologists  were  of  the  opinion   that   this 


27 

dislocation,  without  the  existence  of  adhesions,  was  a 
rarity.  He  did  not,  however,  regard  it  as  such,  and  be- 
lieved that  in  ninety  per  cent,  of  cases  of  retroversion 
the  uterus  could  be  replaced  and  kept  there,  and  that 
those  cases  in  which  it  could  not  be  replaced,  in  conse- 
quence of  adhesions,  were  very  rare. 

With  regard  to  the  diagnosis  of  salpingitis,  we  had  to 
divide  the  cases  into  two  classes  :  first,  ordinary  salpin- 
gitis with  slight  exudation,  and,  second,  the  disease  in  its 
later  stages,  where  we  had  pyo-  or  hydro-salpinx. 

In  the  first  instance  it  was  not  necessary  at  all  to  feel 
the  tube,  but  if  there  was  decided  perimetritis,  with  ca- 
tarrh, minute  condylomata  about  the  hymen  and  la- 
bia minora,  and  erosion  around  the  orifice  of  the  vulvo- 
vaginal glands,  we  knew  that  salpingitis  existed,  because 
the  cases  where  perimetritis  existed  without  salpingitis 
were  so  extremely  rare  that  those  cases  in  which  it  did 
not  belonged  to  the  exceptions. 

In  the  second  instance,  the  shape  of  the  tumor  was  of 
great  miportance  in  diagnosis.  The  tumor  in  salpingitis 
was,  as  a  rule,  not  a  single  one,  but  a  tumor  divided  into 
two  or  three  sections,  and  of  the  shape  of  a  cone  running 
in  the  direction  of  the  lateral  diameter  of  the  pelvis.  In 
very  doubtful  cases  we  could  touch  the  tubes  directly  by 
the  recto-vesical  touch. 

The  large  majority  of  cases  of  salpingitis  were  not 
ready  for  surgical  operation,  and  the  treatment  in  such 
cases  was  very  much  like  that  described  by  Dr.  Wylie  ; 
but  there  was  one  mode  of  treatment  which  he  had  found 
most  eflScient  of  all,  and  that  was  the  prolonged  use  of 
the  waters  of  Franzensbad,  in  Bohemia. 

Dr.  a.  J.  C.  Skene  said,  with  reference  to  pathology, 
that  he  accepted  the  position  taken  by  Dr.  Noeggeradi, 
and,  so  far  as  his  observation  went,  it  was  rare  to  see 
disease  of  the  Fallopian  tubes  without  having  been  pre- 
ceded by  gonorrhcea.  On  the  other  hand,  he  was  incHned 
to  take  issue  with  Dr.  Noeggerath  with  regard  to  the  rarity 
of  the  occurrence  of  pelvic  peritonitis  wiitiout  disease  of 


28 

the  Fallopian  tubes,  for  he  thought  that  such  cases  oc- 
curred not  infrequently. 

With  reference  to  the  question  of  diagnosis,  Dr.  Skene 
accepted  what  had  been  stated  by  Dr.  Wylie  and  Dr. 
Noeggerath,  but  the  practical  difficulty  seemed  to  be  in 
distinguishing  between  simple  ovarian  cysts  in  the  pro- 
lapsed condition  and  pyo-  or  hydro-salpinx  ;  perhaps  the 
difference  was  most  marked  with  reference  to  hydro-sal- 
pinx. There  was  one  point  to  which  attention  had  not 
been  directed,  and  that  was  differential  diagnosis  by  as- 
piration. If  it  was  true  that  ciliated  epithelia  were  so 
generally  present,  what  objection  could  there  be  to  re- 
moving by  aspiration  a  portion  of  fluid  and  examining  it 
under  the  microscope  ?  Out  of  twenty-one  specimens 
which  he  had  examined,  ciliated  epithelia  had  been  found 
in  eighteen^  thus  indicating  the  condition  that  was 
present. 

This  fact  also  raised  a  question  with  regard  to  treat- 
ment. If  the  operation  for  removal  of  the  tubes  could 
be  avoided — an  operation  which,  to  his  mind,  was  some- 
thing of  a  fearful  necessity — it  was  certainly  a  step  which 
no  one  would  hesitate  to  take.  After  aspiration,  a  hydro- 
salpinx might  not  refill,  and  the  aspiration  might  be  fol- 
lowed by  recovery.  If  the  diseased  tube  could  be  thor- 
oughly evacuated,  the  chances  were  that  the  cases  would 
terminate  in  recovery  in  many  instances.  He  thought, 
therefore,  it  would  be  well,  many  times,  to  try  aspiration 
more  thoroughly  than  it  had  yet  been  tried,  both  as  a 
means  of  diagnosis  and  as  a  means  of  treatment. 

Dr.  p.  F.  Mund:^,  since  he  had  had  opportunity  to 
follow  out  Dr.  Noeggerath's  teachings,  and  since  Tait 
had  published  his  successes  in  operating,  had  investigated 
this  class  of  cases  with  special  reference  to  diagnosis,  and 
it  was  yet  the  one  point  upon  which  he  was  not  at  all 
satisfied.  Dr.  Wylie  had  been  unable  to  give  any  new 
"information  on  this  part  of  the  subject,  and  Dr.  Munde 
thought  it  was  impossible  to  make  a  diagnosis  in  the  very 
cases   in    which   it    was   most   desirable.      In    cases   of 


pyo-  and  hydro-salpinx,  the  diagnosis  could  be  made 
either  with  the  fingers  or  by  the  use  of  the  aspirator. 
The  cases  in  which  diagnosis  was  most  desirable  were  not 
those  in  which  there  was  a  soft  sausage-hke  tumor  that 
could  be  distinctly  felt,  but  they  were  those  where  there 
existed  a  diffuse  thickening  or  infiltration  of  the  tissues 
in  each  side  of  the  pelvis,  in  which  the  patient  complained 
of  pain  upon  pressure,  and  pain  at  irregular  intervals, 
with,  perhaps,  discharges  of  small  quantities  of  pus.  It 
was  in  such  instances  that  the  diagnosis  was  most  diflii- 
cult,  and  in  those  cases  Dr.  Munde  believed  that  the  only 
positive  assurance  on  this  point  rested  in  exploratory  in- 
cision. 

Furthermore,  he  did  not  believe  yet  that  laparotomy 
would  be  very  frequently  performed.  So  long  as  we  have 
no  means  of  making  a  clear  diagnosis,  the  operation  will 
not  be  as  popular  as  could  be  wished. 

With  regard  to  the  influence  of  inflammation  of  the 
tubes  upon  uterine  displacements,  he  agreed  with  Dr. 
Noeggerath  that  lateral  displacements  were  the  most  fre- 
quent, but  he  had  seen  retro-displacements  after  chronic 
salpingitis,  and  thought  that  while  they  were  not  as  com- 
mon as  lateral,  they  were  more  frequent  than  anterior 
displacements. 

Concerning  adhesions,  he  agreed  with  Dr.  Noeg- 
gerath, that  in  the  majority  of  cases  of  retroversion  the 
uterus  was  not  adherent. 

With  reference  to  treatment  other  than  by  laparotomy. 
Dr.  Munde  thought  we  were  rather  at  loss,  and  that  but 
little  could  be  done.  He  had  in  some  cases  in  which 
there  was  nothing  but  a  diffuse  swelling,  seen  more  bene- 
fit follow  the  local  application  of  the  constant  electric 
current  than  from  any  other  means,  using  from  twelve  to 
sixteen  cells  of  the  ordinary  battery,  with  sittings  of  from 
fifteen  to  twenty  minutes  every  day  or  every  other  day. 
The  benefit  which  had  followed  this  treatment,  according 
to  his  experience,  was  not  in  the  way  of  greatly  diminishing 
the  exudation,  or  in  reducing  the  adhesions,  but  in  allaying 


30 

the  pain.     This,  however,  did  not  cure  pyo-salpinx  with 
distinctly  diseased  tubes. 

From  our  present  stand-point  he  thought  that  Dr. 
Wylie's  paper  had  been  so  complete  as  to  leave  but  very 
little  to  offer  in  the  way  of  discussion. 

Dr.  Wylie  felt  satisfied  that  if  Dr.  Munde  would  take 
the  pains  to  adopt  his  method  of  preparatory  treatment 
in  those  cases  in  which  there  was  a  marked  diffuse  in- 
duration, with  fulness  in  the  iliac  regions,  the  diagnosis 
would  become  quite  easy.  In  his  first  cases  he  was  in 
doubt,  as  was  Dr.  Munde,  but  in  his  later  cases  he  had, 
by  the  use  of  glycerine  and  alum  applied  on  a  thin  pled- 
get of  cotton  two  or  three  times  a  week,  been  able  to  so 
reduce  the  thickening  as  to  enable  him  by  digital  exam- 
ination to  diagnosticate  the  exact  condition  of  affairs 
within  the  pelvis. 

Dr.  Wylie  doubted  if  hydrosalpinx  would  be  cured  by 
aspiration.  With  reference  to  diagnosis  by  means  of  the 
aspirator,  he  thought  that,  as  a  rule,  if  there  was  a  large 
tumor,  either  a  dilated  tube  or  a  cystic  ovary,  it  would 
be  much  safer  not  to  tap,  as  Tait  had  so  well  observed, 
abdominal  tumors  upon  which  it  was  proposed  to  operate. 
Probably  it  was  only  in  the  cases  in  which  there  was  a 
single  cyst  in  which  any  benefit  would  be  obtained.  With 
reference  to  retroversion  being  associated  with  salpingitis, 
he  thought  that,  in  women  who  had  never  borne  children, 
lateral  version  of  the  uterus  was  the  most  frequent  dis- 
placement;  but  that  in  the  majority  of  cases  occurring 
in  women  who  had  borne  children,  especially  where  there 
was  salpingitis  due  to  septic  endometritis,  retroversion 
was  almost  invariably  present.  His  experience,  there- 
fore, was  that,  in  cases  in  which  salpingitis  arose  from 
septic-poisoning,  retroversion  was  a  frequent  accompani- 
ment. 


NEW   YORK  PATHOLOGICAL   SOCIETY. 

Stated  Meetings  Ja7iimry  14,  1885. 

George  F.  Shrady,  M.D.,  President,  in  the  Chair. 

cases  of  salpingitis results  of  operation. 

Dr.  W.  Gill  Wylie  exhibited  a  number  of  specimens 
of  salpingitis  removed  by  laparotomy,  and  made  the  fol- 
lowing remarks  : 

"  Mr.  President  :  I  will  read  short  histories  of  four- 
teen cases  of  salpingitis  which  I  have  operated  upon  since 
May,  1883,  and  I  have  here  for  presentation  the  speci- 
mens from  twelve  of  these  cases,  with  a  report  on  each 
by  Dr.  Henry  C.  Coe,  Pathologist  to  the  Woman's  Hos- 
pital of  the  State  of  New  York.  Nine  were  operated  on 
in  Bellevue  Hospital  and  five  in  private  practice.  Twelve 
of  the  fourteen  recovered,  and  t\vo  died  from  the  effects 
of  the  operation.  Both  of  the  latter  were  hospital  cases, 
and  both  died  on  the  fifth  or  sixth  day  from  septicaemia. 

"  Case  I. — Mrs.  R ,  aged  thirty-two,  married,  the 

mother  of  two  children,  has  had  two  miscarriages.  Her 
present  trouble  dates  from  an  abortion,  three  years  ago, 
although  she  has  always  suffered  from  more  or  less  dys- 
menorrhoea.  She  complains  now  of  severe  dragging 
pains  on  both  sides  of  the  pelvis.  Two  years  ago  she 
underwent  an  operation  for  lacerated  cervix.  Examina- 
tion reveals  the  uterus  movable,  but  retroverted,  the  tubes 
and  ovaries  prolapsed,  sensitive,  enlarged,  and  easily 
made  out,  while  by  slowly  pressing  the  left  tube  a  gleety 
pus  can  be  made  to  appear  in  the  vagina.     Operation, 


32 

May  26,1883.     She  made  a  good  recovery  from  opera- 
tion. 

'''■Examination  of  specimens. — Both  tubes  are  found 
dilated  and  adherent  to  the  corresponding  ovaries,  which 
appear  to  be  the  seat  of  a  chronic  ovaritis.  The  distal 
end  of  one  of  the  tubes  has  been  so  fused  with  the  ovary, 
as  the  result  of  old  inflammations,  that  the  fimbriae  and 
opening  have  been  entirely  obliterated.  In  the  other 
tube,  which  is  less  dilated,  the  lumen  is  patent.  Micro- 
scopic examination  of  the  contents  of  the  most  diseased 
tube  showed  it  to  consist  largely  of  pus  and  fatty  degen- 
erated epithelial  cells.  A  few  ciliated  cells  were  also 
noticed.  A  small  amount  of  pus  was  observed  in  the 
fluid  taken  from  the  other  tube. 

"  Notwithstanding  the  fact  that  both  tubes  were  com- 
pletely removed,  the  patient  has  menstruated,  with  one 
or  two  exceptions,  regularly  every  month.  The  amount 
of  flow  became  excessive,  lasting  eight  or  ten  days.  She 
was  curetted ;  but  three  months  later,  after  menstruating 
regularly,  it  was  necessary  to  curette  again,  and  nine 
months  later  curetting  was  repeated.  Granulations 
were  found  each  time,  but  nothing  mahgnant  was  dis- 
covered by  a  careful  examination  made  by  Dr.  W.  H. 
Welch.  Now,  nearly  two  years  after  the  operation,  she  still 
menstruates  every  month,  but  is  able  to  go  about,  and 
except  for  a  ventral  hernia  would  be  comparatively  well. 
The  uterus  is  a  little  above  the  normal  size. 

"  Case  II. — M.  I, ,  aged  twenty-five,  a  native  of 

France,  married,  but  no  childen.  Was  admitted  May  30, 
1883.  She  gave  a  history  of  gonorrhoea,  and  complains 
of  pain  over  the  ovaries,  dysmenorrhoea,  and  leucorrhoea. 
On  examination  the  uterus  was  found  retroverted,  and 
after  some  treatment  a  prolapsed  tube  and  enlarged  ovary 
were  also  discovered.  Operation,  June  25,  1883.  The 
patient  made  a  good  recovery,  but  still  complained  of 
pains,  notwithstanding  both  ovaries  and  tubes  were  re- 
moved. She  was  kept  under  observation  till  September, 
and  then  discharged.  It  was  afterward  heard  that  she 
had  a  ventral  hernia. 


33 

*'  Examination  of  the  specimen. — Hoth  ovaries  and  tubes 
were  removed  in  the  operation.  It  was  found  that  the 
one  ovary  and  the  fimbriated  extremity  of  its  correspond- 
ing tube  were  so  fused  together  that  they  could  not  be 
separated.  The  aj^pearance  presented  was  such  as  to 
suggest  a  normal  tube  terminating  in  a  cystic  ovary.  On 
passing  a  probe  through  the  cut  end  of  the  tube,  a  por- 
tion of  this  cyst  is  found  to  be  the  dilated  tube,  though 
the  line  of  separation  between  the  latter  and  the  cystic 
ovary  could  not  be  made  out.  Many  adhesions  were  also 
present.  A  drop  of  the  watery  fluid  obtained  from  the 
tube  was  found  to  contain  a  small  amount  of  i)us,  broken- 
down  cells,  and  granular  debris.  Some  ciliated  cells  were 
still  preserved,  as  if  they  had  been  among  the  last  to 
suffer  disintegration.  The  condition  in  this  tube  was  one 
rather  of  hydro-  than  pyo-salpinx.  The  other  ovary  was 
small  and  atrophied.  The  tube  was  distinct  from  the 
ovary.  Its  fimbriae  had  entirely  disappeared,  and  at  the 
distal  end  there  was  a  small  but  distinct  cicatrix  marking 
the  site  of  the  inflammatory  process  which  obliterated 
the  opening.  A  probe  can  be  passed  through  the  tube 
from  the  cut  end,  but  is  arrested  at  this  artificial  septum. 
The  tube  contains  a  reddish  fluid,  a  drop  of  which  shows, 
under  the  microscope,  pus,  broken-down  cells,  and  granu- 
lar debris, 

"Case  III. — T.  S ,  twenty-seven  years  of  age,  a 

native  of  Italy,  married,  the  mother  of  two  children. 
Admitted  April  28,  1883.  She  suffers  from  dysmenorrhoea 
and  leucorrhoea.  For  more  than  a  year  she  has  had  a 
severe  pain  in  the  right  iliac  fossa,  which,  since  the  birth  of 
her  last  child  in  February  last  has  been  excruciating.  She 
gives  a  history  of  gonorrhoea,  which  was  confirmed  by 
vegetations  in  the  vagina.  On  examination  the  physical 
signs  of  a  local  peritonitis  are  found.  Operation,  Octo- 
ber 28,  1883,  shows  a  catarrhal  state  of  the  tubes  and  in- 
durated ovaries.  She  made  a  good  recovery,  but  still 
suffered  much  from  the  old  pain,  but  gradually  got  better 
and  was  discharged  cured  December,  1S83. 


34 

"  Exaininatio7i  of  specimen. — The  ovaries  ^  obtained 
from  this  case  show  a  decided  increase  in  the  density  of 
the  fibrous  stroma  and  thickening  of  the  cortical  zone.  A 
few  cysts  are  also  present.  The  tubes  are  long  and  tor- 
tuous, but  appear  to  be  of  normal  size.  Their  fimbriated 
extremities  are  normal,  and  the  lumina patent  throughout. 
The  specimen  is  so  shrunken  that  it  is  impossible  to  say 
whether  the  tubes  were  originally  diseased  or  not,  prob- 
ably they  were  not  affected. 

"Case  IV. — A.  S ,  a  native  of  Ireland,  thirty-one 

years  of  age,  married,  and  the  mother  of  two  children. 
Admitted  November  i,  1883.  She  is  suffering  from  dys- 
menorrhoea.  For  the  last  ten  years  she  has  vomited  sev- 
eral days  every  month,  and  besides  suffers  from  severe 
pain  in  the  right  iliac  region.  Her  general  health  is  poor. 
On  examination  the  uterus  was  found  displaced  to  the 
left  and  more  or  less  fixed ;  marked  pelvic  adhesions 
were  present ;  the  ovaries  were  sensitive.  Operation, 
December  8,  1883.  It  showed  that  the  omentum  was 
adherent  over  the  pelvic  organs,  and  that  both  ovaries 
and  tubes  were  fixed  by  fine  adhesions.  The  pedicle 
w^as  so  short  that  both  sides  had  to  be  tied  a  second  time, 
and  on  the  right  side  the  arteries  had  to  be  picked  up 
with  artery  forceps  on  account  of  the  slipping  of  the  lig- 
ature. To  do  this  the  abdominal  opening  had  to  be 
made  larger  and  kept  exposed  for  nearly  an  hour.  All 
bleeding  was,  however,  effectually  stopped.  The  patient 
did  not  rally  well,  but  there  was  little  rise  of  tempera- 
ture till  the  fourth  day,  when  it  steadily  increased,  and  at 
the  end  of  the  fifth  day  had  reached  106°.  Death  oc- 
curred from  septiccemia. 

"  Examination  of  the  specime7i. — One  tube  showed  but 
little  change.  It  had  become  adherent  to  the  ovary, 
probably  as  the  result  of  an  old  peritonitis.  There  was 
marked  dilatation  and  thickening  near  the  fimbriated  ex- 
tremity, but  the  lumen  was  patent.     The  corresponding 

1  The   specimen   has  been   preserved  for  several   months  in  chromic  acid,  and 
hence  is  nearly  useless  for  gross  examination. 


35 

ovary  was  cystic.  The  opi)osite  tube  was  considerably 
enlarged,  its  wall  thickened,  and  dilated  near  the  distal 
end.  The  fimbriated  opening  was  buried  in  a  mass  of 
old  adhesions.  The  fluid  removed  from  this  tube  con- 
tained [)us  in  small  amount,  granular  epithelial  cells,  and 
a  considerable  amount  of  granular  detritus.  Several 
groups  of  columnar  epithelial  cells  were  seen,  a  few  of 
which  still  retained  their  cilia. 

"  This  specimen  was  seen  when  fresh  by  Dr.  Welch  ; 
he  noted  much  congestion  of  the  tubes,  and  marked  pel- 
vic ])eritonitis. 

"  Case  V. — Miss  B ,  a  native  of  the  Uniied  Slates, 

twenty-three  years  of  age,  smgle.  She  has  suffered  for 
several  years  from  slight  dysmenorrhoea  and  leucorrhcea. 
She  gives  a  history  of  hystero-epilepsy  commencing  sev- 
eral years  ago,  and  becoming  more  and  more  severe,  till 
now  she  has  sometimes  a  number  of  severe  attacks  each 
day.  Physical  examination  showed  the  ovaries  enlarged, 
and  plainly  to  be  felt,  of  the  size  of  English  walnuts. 
The  uterus  was  movable  and  in  its  normal  i)osition.  The 
tubes  could  not  be  made  out  as  enlarged.  Operation, 
December  3,  1883.  The  patient  made  a  good  recovery, 
without  a  single  bad  symptom.  Both  ovaries  and  tubes 
were  removed. 

'•'■  Examination  of  specimen. — Only  one  tube  and  ovarv 
preserved.  The  ovary  is  of  the  size  of  an  English  walnut 
and  extensively  diseased.  The  cai:)sule  is  thickened,  and 
at  the  periphery  a  large  cyst  is  seen.  As  the  organ  gives 
an  obscure  sense  of  fluctuation,  it  is  doubtless  cystic 
throughout.  (The  ovary  in  the  specimen  was  entirely 
separated  from  the  tube,  and  only  a  small  piece,  about 
one  and  a  half  centimetre,  of  the  corresponding  tube  has 
been  preserved,  and  this  is  hard  to  distinguish,  except  by 
laying  it  open  and  examining  the  lining  mucous  membrane 
under  the  microscope.)  The  fimbriated  end  was  originally 
closed  by  a  cicatricial  mass,  which  was  divided.  There  is 
a  small  cyst  of  the  broad  ligament  just  belov/  the  obliter- 
ated distal  end.     No  fluid  was  found  in  the  tube. 


36 

"Case   VI. — Hydrosalpinx    {hospital  patient), — M. 

B ,  a  native  of  Ireland,  married,  one  child.    Admitted, 

November  17,  1883.  She  is  bed-ridden,  and  has  been 
treated  for  menorrhagia.  She  complains  of  severe  pain 
and  tenderness  over  the  left  side.  Examination  shows 
the  uterus  retroverted  somewhat,  and  a  mass  the  size  of  a 
small  hen's  Qgg  can  be  felt  to  the  left  of  the  fundus  in  the 
left  broad  ligament.  Operation,  January  27,  1884.  Not- 
withstanding a  slight  rise  of  temperature  the  first  three 
days  after  the  operation,  she  made  a  good  recovery.  The 
left  ovary  and  tube  were  found  enlarged  and  diseased, 
but  the  right  perfectly  normal  and  free  from  adhesions, 
and  were  therefore  left  undisturbed. 

'•''  Examination  of  speci^nen. — Inspection  of  the  dis- 
eased tube  shows  it  to  be  enlarged  to  the  size  of  a  finger, 
and  its  walls  much  thinner  than  normal.  Evidences  of 
adhesion  are  to  be  seen  all  over  its  exterior.  The  distal 
opening  has  been  entirely  obliterated,  evidently  the  result 
of  previous  inflammation.  The  accompanying  ovary  is 
enlarged  to  the  size  of  an  Enghsh  walnut.  It  was  evi- 
dently much  larger  before  removal,  as  it  contained  a  cen- 
tral cyst  as  large  as  a  marble.  The  fluid  found  within  the 
tube  contained  nothing  but  a  large  number  of  round  and 
columnar  epithelial  cells.  Many  groups  of  well-preserved 
ciliated  cells  were  found,  looking  as  perfect  as  if  they  had 
just  been  removed. 

"  Case  VII. — L.   D ■,  twenty-eight   years    of  age, 

married  but  sterile.  Admitted  September,  1883.  She 
suffers  from  dysmenorrhoea,  has  been  bed-ridden  for 
months  at  times,  and  has  already  been  in  four  hospitals. 
She  complains  of  pain  in  the  back  and  head,  and  vomits 
almost  every  day.  Her  pulse  is  always  over  100.  For 
several  years  she  has  been  unable  to  work,  and  is  com- 
pletely demoralized.  When  examined,  the  uterus  was 
found  retroverted  fixed,  the  tubes  and  ovaries  could  be 
made  out  slightly  enlarged.  Operation,  March  3,  1884. 
She  did  well  for  two  weeks,  when  the  temperature  rose 
to  104°,  but  this  was  unaccompanied  by  pain  or  tender- 


37 

ness.  She  had  also  a  slight  cough,  and  this,  together 
with  the  elevated  temperature,  was  regarded  of  pulmonary 
origin.  Gradually,  however,  she  got  stronger,  and  was 
discharged  cured  September,  1884. 

'■'■  Examivatioii  of  specimen. — The  ovaries  are  found  to 
be  of  normal  size,  but  cystic.  The  corresponding  tubes 
are  enlarged  and  dilated.  The  condition  is  nearly  the 
same  as  in  Case  I.,  except  that  here  both  distal  apertures 
seem  to  have  been  obliterated  by  old  inflammation.  One 
tube  is  closely  adherent  to  the  corresponding  ovary,  the 
other  only  partially.  They  both  give  a  distinct  sense  of 
fluctuation,  and  on  introducing  a  needle,  a  watery  fluid 
is  obtained  which  shows  under  the  microscope  a  few 
mucous  corpuscles  and  normal  epithelial  cells.  A  con- 
siderable number  of  perfect  ciliated  cells  were  also  pres- 
ent. The  condition  may  be  termed  one  of  moderate  hy- 
dro-salpynx. 

"  Case  VIII. — Mrs.  Mc ,  a  native  of  the  United 

States,  aged  twenty-seven,  married,  and  has  had  one 
miscarriage  at  four  months,  but  no  children.  She  has 
suffered  greatly  from  dysmenorrhcea  and  menorrhagia. 
Her  general  health  is  poor,  and  she  has  been  a  con- 
firmed invalid  for  the  last  ten  years,  being  confined  to 
bed  most  of  the  time.  She  complains  also  of  an  almost 
constant  pain  in  the  iliac  region,  back,  etc.  Examina- 
tion shows  the  uterus  anteverted;  the  left  ovary  and 
tube  enlarged  and  adherent ;  the  ovary  also  enlarged. 
Operation,  March  13,  1884,  and  it  was  found  that  the 
right  ovary  was  slightly  adherent  and  cystic,  while  the 
left  tube  and  ovary  were  enlarged  and  very  firmly  ad- 
herent. The  patient  recovered  without  a  single  bad 
symptom.  Examination  of  the  removed  tubes  and  ova- 
ries showed  the  one  tube  and  ovary  normal  to  all  ap- 
pearances, although  the  wall  of  the  tube  seems  to  be  a 
little  thicker  than  usual.  The  other  tube  was  uniformly 
enlarged,  and  its  mucous  membrane  swollen.  The  lu- 
men was  patent,  but  no  fluid  was  present.  The  corre- 
sponding ovary  was  enlarged  and  cystic.     The  condition 


38 

was  probably  one  of  catarrhal  salpingitis,  leading  to 
hypertrophy  of  the  mucous  membrane,  and,  perhaps, 
also  of  the  muscular  layer  of  the  wall  of  the  tube. 

"  Case  IX. — H.  D ,  colored,  a  native  of  the  United 

States,  aged  twenty-seven,  married,  but  sterile.  Admit- 
ted February  3,  1884.  She  is  suffering  from  dysmenor- 
rhoea,  and  has  had  severe  local  pains  in  the  left  iliac 
region  for  the  past  three  years,  making  her  a  complete 
bed-ridden  invalid.  Examination  showed  the  uterus  an- 
teflexed  and  firmly  fixed,  and  the  enlarged  ovaries  and 
tubes  could  be  felt,  especially  on  the  left  side.  Opera- 
tion, March  20,  1884.  She  had  adhesions,  about  the 
worst  I  ever  saw,  the  omentum,  bladder,  intestines,  etc., 
being  all  involved.  A  pedicle  on  the  left  side  could  not 
be  secured,  and  the  arteries  were  picked  up  by  forceps, 
necessitating  a  prolongation  of  the  operation  and  expos- 
ure of  the  peritoneum.  She  gave  symptoms  almost  iden- 
tical w^ith  Case  IV.,  and  died  of  septiccemia  on  the  fifth 
day.  Both  tubes  and  ovaries  were  removed  in  the  oper- 
ation. 

'■^  Exatnination  of  specimen. — Both  tubes  were  found  to 
be  enlarged  and  thickened,  but  not  dilated.  They  were 
buried  in  masses  of  adhesions,  though  the  lumina  seemed 
to  be  open.  Both  ovaries  were  the  seat  of  marked  cys- 
tic degeneration.  In  one  broad  ligament  was  a  cyst  the 
size  of  a  large  walnut.  Microscopic  examination  of  the 
mucous  membrane  of  the  tubes  showed  it  to  be  much 
swollen  and  covered  by  leucocytes.  No  epithelial  cells 
were  preserved.  In  this  case  there  had  probably  been 
a  chronic  catarrh  of  the  tubes,  which  led  to  thickening 
of  the  mucous  membrane.  Some  of  the  thickening  could 
also  be  attributed  to  an  old  peri-salpingitis. 

"  Case    X. — Mrs.   O ,  aged   twenty-five,  married 

two  and  a  half  years,  but  sterile.  Before  marriage  she 
was  perfectly  well,  but  soon  after  this  she  began  to  suffer 
from  dysmenorrhcea  and  leucorrhoea.  For  more  than  a 
year  she  has  had  severe  pains  first  on  the  right  and  then 
on    the   left   side.     Lately   she   has   also    suffered  from 


39 

menorrhagia.  Examination  showed  the  uterus  anteverted 
and  imbedded  in  a  mass  of  indurated  tissue,  and  the  en- 
larged ovaries  and  tubes  could  be  also  made  out.  She 
was  kept  under  observation  and  treatment  for  a  year 
previous  to  operation.  The  operation  was  performed 
May  I,  1884.  The  omentum  was  found  coverijjtg  all  the 
pelvic  organs.  Both  ovaries  were  imbedded  in  a  mass  of 
adhesions  and  very  much  enlarged.  The  left  ovary  was 
of  the  size  of  a  lemon  and  filled  with  abscesses.  The 
corresponding  tube  is  firmly  adherent  and  infiltrated  with 
pus.  The  right  tube  and  ovary  are  not  as  much  enlarged, 
but  a  number  of  small  pus-centres  were  noticed  as  the 
adhesions  were  broken  up.  The  patient  made  a  good 
recovery,  except  that  an  abscess  formed  around  the  stump 
on  the  left  side  and  the  track  of  the  drainage-tube  dis- 
charged for  several  months.  Pyo-salpinx  and  ovaritis. 
Specimen  accidentally  thrown  away. 

"  Case  XI. — M.  H ,  aged  thirty-two,  married,  and 

has  had  one  child  and  three  miscarriages.  Admitted 
September,  1884.  She  is  suffering  from  dysmenorrho^a. 
She  had  a  miscarriage  six  months  ago,  and  for  nearly  two 
months  has  had  a  septic  fever.  She  complains  of  a 
severe  pain  in  the  iliac  region.  On  examination  the 
uterus  is  found  retroverted  ;  the  ovaries  and  tubes  en- 
larged and  sensitive.  Operation,  October  9,  18S4.  Exten- 
sive adhesions  were  found,  the  omentum,  small  intestines, 
etc.,  being  involved.  The  tissues  of  the  tubes  and  of  one 
ovary  were  so  softened  and  infiltrated  that  the  ligature 
cut  entirely  through  the  pedicle,  and  the  blood-vessels 
had  to  be  picked  up  and  tied  separately.  Abscesses  on 
both  sides,  involving  the  ends  of  the  tubes,  were  met  with. 
A  drainage-tube  was  inserted  and  the  patient  made  an 
excellent  recovery,  and  was  discharged  cured,  November 
18,  1884,  all  pains  relieved. 

^'- Exajiiination  of  specimcji, — The  specimen  obtained 
from  this  case  is  the  best  in  the  collecdon.  It  consists  of 
two  greatly  enlarged  tubes  with  their  corresponding 
ovaries.     The  smaller  of  the  tubes  is  about  the  size  of  a 


40 

large  lead  pencil,  and  shows  on  its  exterior  evidences  of 
previous  inflammation.  The  accompanying  mesosalpinx 
is  much  thickened.  The  fimbriated  extrennt}'  of  this 
tube  is  patent,  so  that  on  compressing  the  walls  a  quantity 
of  thick,  reddish-yellow  fluid  escaped.  This  on  examina- 
tion was  found  to  contain  pus,  fatty  degenerated  epithe- 
lial cells,  free  fat,  fatty  acid  crystals,  and  bits  of  smooth 
muscular  fibres,  but  no  ciliated  cells.  The  other  tube  is 
as  large  as  the  forefinger,  much  distorted,  and  its  fimbri- 
ated extremity  buried  in  a  mass  of  adhesions,  which  also 
partly  envelop  the  ovary.  The  distal  end  is  completely 
closed.  The  corresponding  ovary  is  cystic ;  its  cortex 
greatly  thickened.  There  are  many  evidences  of  recent 
peri-oophoritis.  The  opposite  ovary  is  nearly  normal  in 
size  and  appearance.  The  fluid  removed  from  the  larger 
tube  contains  a  large  amount  of  pus  and  fatty  degenerated 
epithelial  cells,  and  much  free  fat.  Groups  of  columnar 
epithelial  cells  are  found,  but  no  cilias  are  observed. 
There  are  numbers  of  spindle  cells  from  the  muscular 
layers,  pointing  to  advanced  changes  in  the  wall  of  the 
tube.     This  is  a  typical  example  of  pyo- salpinx. 

"  Case  XII. — Miss  W ,  twenty-eight  years  of  age, 

single.  She  suffers  from  very  severe  dysmenorrhoea. 
She  complains  of  pain  in  the  back,  head,  neck,  etc,  and 
has  been  a  confirmed  invalid  for  several  years.  Exam- 
ination showed  the  uterus  retroverted  and  retroflexed, 
being  held  back  by  bands  of  adhesions,  and  very  sensitive 
and  boggy.  The  tubes  could  not  be  made  out  as  en- 
larged. The  ovaries  are  prolapsed  and  seem  cystic. 
Operation,  October  20,  1884.  Extensive  adhesions  were 
found,  although  the  tubes  were  the  principal  bands  hold- 
ing back  the  uterus.  They  were  thickened,  but  not  dis- 
tended. The  ovaries  were  cystic  and  fixed  by  adhesions. 
The  patient  made  a  good  recovery.  The  specimen  was 
lost. 

''  Case  XIII. — Mrs.   C ,   a  native  of  the  United 

States,  married,  and  the  mother  of  one  child.  Admitted 
October  30,  1884.     She  suffers  from  dysmenorrhoea,  and 


41 

has  had  severe  pain  in  the  left  iliac  region  since  the  birth 
of  her  child.  On  examination  the  uterus  was  found  lat- 
erally flexed,  and  the  enlarged  left  ovary  and  tube  could 
be  plainly  made  out  in  the  left  broad  ligament.  Oi^era- 
tion,  November  29,  1884.  The  left  ovary  and  tube  were 
removed  (the  right  being  normal).  The  patient  made  a 
good  recovery  and  left  well  when  discharged,  December 
28,  1884. 

^''Examination  of  the  speciinen. — The  ovary  is  atrophied 
and  buried  in  a  mass  of  adhesions.  The  peritoneal  sur- 
face of  the  tube  is  thickened,  intensely  congested,  and 
covered  with  adhesions.  The  same  is  true  of  the  meso- 
salpinx. The  tube  is  enlarged  to  two  or  three  times  its 
normal  size,  its  walls  are  thickened,  and  it  gives,  on 
pressing  it  between  the  fingers,  an  obscure  feeling  of 
fluctuation.  The  fimbriae  are  still  preserved,  and  the 
constriction  of  the  lumen  seems  here  to  be  at  the  proxi- 
mal rather  than  distal  end  of  the  tube.  On  pressing  the 
tube  pus  flows  from  the  fimbriated  end.  This  examined 
microscopically  is  found  to  contain  a  large  number  of 
pus  corpuscles,  fatty  epithelial  cells,  and  granular  detritus. 
Several  quite  perfect  ciliated  cells  were  also  seen. 

"  Case  XIV. — M.  C ,  a  native  of  Italy,  married, 

has  had  three  children  and  two  miscarriages.  Admitted 
October  15,  1884.  She  is  suffering  from  menorrhagia, 
and  complains  of  intense  pain,  chiefly  in  the  right  iliac 
region,  for  the  last  three  years.  On  examination  the 
uterus  is  found  fixed  and  adherent,  being  drawn  backward 
toward  the  sacrum.  Under  ether  an  enlarged  tube  can 
be  plainly  felt  on  the  right  side.  Operation,  December 
8th.  The  patient  made  a  good  recovery  and  was  dis- 
charged January  8th,  the  pain  being  completely  relieved. 

"  Examination  of  specimen. — One  ovary  is  about  twice 
the  normal  size,  and  seems  to  be  almost  entirely  made  up 
of  one  large  cyst.  The  other  is  considerably  atrophied. 
The  tube  corresponding  to  the  larger  ovary  is  enlarged  to 
twice  its  normal  dimensions,  and  the  fimbri.-e  have  dis- 
appeared, the  fimbriated  opening  being   obUterated   by 


42 

old  adhesions.  The  proximal  cut  end  admits  a  large 
probe,  and  a  drop  of  yellowish  fluid  can  be  squeezed 
from  it,  which  shows,  under  the  microscope,  piis,  broken- 
down  epithelium  (some  with  perfect  cilia),  and  a  large 
amount  of  granular  debris.  The  other  tube  is  enlarged, 
much  distorted,  and  is  bent  on  itself  near  the  fimbriated 
end,  so  that  the  fimbrice  seem  to  spring  almost  from  the 
middle  rather  than  from  the  end  of  the  tube.  A  probe 
may  be  introduced  into  the  distal  opening  for  a  short 
distance.  There  are  evidences  of  previous  inflammation, 
leading  to  thickening  of  the  mesosalpinx  and  peritoneal 
covering  of  the  tube.  A  drop  of  fluid,  obtained  from 
the  distended  distal  end,  is  shown  by  microscopic  exam- 
ination to  contain  a  moderate  number  of  pus  corpuscles, 
many  round,  pyriform,  and  columnar  ciliated  cells,  free 
nuclei,  and  granular  detritus. 


No.  of 
case. 

Age. 

Condition. 

Chil- 
dren. 

Miscar- 
riages. 

Disease. 

Result. 

I.. 

32 

Married. 

2 

2 

Pj'osalpinx. 

Recovered. 

II.. 

25 

" 

0 

0 

" 

" 

III.. 

27 

" 

2 

0 

Catarrhal  s. 

" 

IV.. 

31 

'< 

2 

0 

Pyosalpinx. 

Died. 

v.. 

23 

Single. 

0 

0 

Catarrhal  s. 

Recovered. 

VI.. 

29 

Married. 

I 

0 

Hydrosalpinx. 

" 

VII.. 

28 

" 

0 

0 

' ' 

VIII.. 

27 

" 

0 

I 

Catarrhal  s. 

" 

IX.. 

27 

" 

0 

0 

Pyosalpinx. 

Died. 

X.. 

25 

" 

0 

0 

" 

Recovered. 

XI.. 

30 

<  ( 

I 

3 

( 1 

" 

XII.. 

28 

Single. 

0 

0 

Catarrhal  s. 

i< 

XIII.. 

26 

Married. 

I 

0 

Pyosalpinx. 

II 

XIV. 

31 

' ' 

3 

2 

ii 

1 1 

"The  hospital  cases  were  selectedfrom  patients  present- 
ing themselves  for  treatment  at  my  clinic  at  the  New 
York  Polyclinic,  where,  during .  the  past  two  years,  I 
personally  examined  607  individual  women.  Of  this 
number  125  had  unmistakable  evidence  of  peri-uterine 
inflammation,  and  of  these  the  lubes  were  plainly  made  out 


43 

as  enlarged  in  i8  cases  on  the  first  examination.  By  the 
use  of  glycerine  and  glycerine  and  alum  tampons  in 
many  others  of  the  125,  diseased  tubes  could  be  made 
out  after  the  thickened  peritoneal  adhesions  had  been 
stretched  and  softened.  In  those  cases  where  diseased 
tubes  could  not  be  defined  by  the  touch,  all  other  symp- 
toms often  indicated  that  they  were  diseased,  and  my 
studies  lead  me  to  the  conclusion  that  peri-uterine  in- 
flammation wl'^ch  is  not  associated  with  diseased  Fallo- 
pian tubes  is  the  exception,  and  that,  as  a  rule,  disease 
of  the  tube  precedes  the  local  peritonitis." 


